PERFORMANCE ASSESSMENT for

PlanningAssessmentInterpersonalDocumentationChild Protection Specialized Services, “Independent Living”,Certification CandidateAssessment Results FormSafetyPermanencyWell-BeingCandidate’s Name:_______________________________________________________________________Date of Hire/Post-Test/Waiver Test (Earliest):______________ Agency Name:______________________________________Case Identification Name or Number:______________________________________________________________________Performance Assessment Attempt Number (circle one): 1 2Each standard in each competency HAS achieved a rating of 3 or higher (or “Yes”) from both evaluators.Therefore, we confirm that the Candidate HAS demonstrated competency as required by the Performance Assessment.Each standard in each competency HAS NOT achieved a rating of 3 or higher (or “Yes”) from both evaluators.Therefore, we confirm that the Candidate HAS NOT demonstrated competency as required by the PerformanceAssessment. The competency(ies) not passed are (please check and explain all that apply):Assessment (A)______________________________________________________________________________Planning/Documentation (B)____________________________________________________________________Interpersonal Skills (C)________________________________________________________________________Please explain above (and on additional sheets, if necessary) all deficiencies noted and what the Candidate must do inorder to demonstrate competency in those areas.We disagree on the results of the Candidate’s Performance Assessment, and will forward the Assessment forreview (per local protocol) and final determination, which is binding.Supervisor’s Name (please print):____________________________________________ Date:________________________Supervisor’s Signature:_________________________________________________________________________________1 st Tier Evaluator’s Name (please print):_______________________________________ Date:________________________1 st Tier Evaluator’s Signature:____________________________________________________________________________2 nd Tier Evaluator’s Name (please print):______________________________________ Date:________________________2 nd Tier Evaluator’s Signature:____________________________________________________________________________I, the undersigned Candidate for Certification, have received the results of the Performance Assessment on this date.Candidate’s Name (please print):___________________________________________Date:________________________Candidate’s Signature:_________________________________________________________________________________The Candidate refused to sign. The Candidate received a copy of this Assessment Results Form. ______________(Supervisor must initial above)8