IFUGAO STATE UNIVERSITY

Nayon, Lamut, Ifugao

PERFORMANCE EVALUATION REPORT FORM
From November 2010-March 2011
OFFICE: Main Campus
DIVISION/SECTION: College of Health Sciences
Employee: JOEFREY D. GAERLAN
Position: Clinical Instructor
Part I: Performance (70%)
Duties and responsibilities PERFORMANCE TARGET RATING
TARGET QUANTITY QUALITY TIME QN QI TIME
Planned Actual Planned Actual Planned Actual
I. INSTRUCTION
1. Prepares course outline, syllabus, Syllabus covers prescribed Syllabus covers prescribed 80 % 95 % Submit before the Submitted before the 6 8 8
instructional material and clinical topics in (NCM 102) topics in (NCM 102) effective effective deadline ( 1 day after the deadline ( 2 days after
teaching plan (CTP) every week Maladaptive Behavior and Maladaptive Behavior and start of classes) the start of classes)
before exposure Rehabilitative Nursing; Rehabilitative Nursing;
prepares 3 Course Outlines, prepares 3 Course Outlines,
1 Instructional Material and 1 Instructional Material and
12 Clinical Teaching 12 Clinical Teaching
Plans(Operating Plans(Operating
Room)every week Room)every week
2. Teach NCM 102 Psychiatric Render 4-hour lecture per Render 4-hour lecture per 85 % 95 % Finish topics before the Finished topics before 8 8 6
Nursing, Communicable Disease and week week effective effective scheduled final the scheduled final
Orthopedic Nursing examinations examinations
3. Design and use instructional 2 drawings/illustrations 2 drawings/illustrations 85 % 95 % Use as needed/scheduled Used as 8 8 6
materials 8x Computer Aided 5x Computer Aided effective effective needed/scheduled
Instruction Instruction
4. Facilitate group activities such as case analysis/ situation case analysis/ situation 80 % 95 % Facilitate activities as Facilitated activities as 8 8 6
case analysis or situation analysis analysis, group discussions, analysis, group discussions, effective effective scheduled scheduled
and group discussion autobiography, lay therapy, autobiography, lay therapy,
music and art therapy, music and art therapy,
socialization and socialization and
culminating activity culminating activity, role
play, case analysis/ situation
analysis, group discussions,
5. Check attendance of students Twice per lecture/ RLE day Twice per lecture/ RLE day 80 % 100 % 15 minutes after the 1st 15 minutes after the 1st 8 8 6
during lecture and RLE duties effective effective hour and 15 minutes hour and 15 minutes
before the lecture or before the lecture or
duty ends duty ends
6. Supervise students in their RLE Assist 4 groups of BSN III
duties in the Operating Room at students
Veterans Regional Hospital and
Ifugao Provincial Hospital
7. Conduct ward class 1 ward class/ group
8. Prepare and submit test questions 100-point examination
composed of multiple
choice, identification,
matching type, true or false
and essay questions
9. Evaluate students’ performance Lecture:2 major
examinations,6 quizzes
Recitations/class
participation
RLE: Actual observation, 2
major exams, 4 evaluation
exam and 2 quizzes/rotation,
2 case presentation/group ,
NCP/student, 1 journal
article
10. Submit reports and grading Submit dully accomplished
sheets PES, DTR and 10 grading
sheets (2 lecture, 4 RLE)
II. DESIGNATION
1. Designated as adviser of BSN III Supervise the class and
conduct 3 meetings; set
consultation hours ( 10 hours
a week or as needed)
Assist 5 groups of BSN III 85 % 100 % b. 8-4, MTW b. 8-4, MTW 8 8 8
students effective effective
6 ward class/ group 80% 100% Spend 8 hours of the 1st Spent 4 hours of the 1st 8 8 6
effective effective day of duty per rotation day of duty per rotation
100-point examination 90 % 100 % Submit questionnaire for Submitted 6 8 8
composed of multiple effective effective encoding and questionnaire for
choice, identification, reproduction 1 week encoding and
matching type, true or false before schedule of major reproduction 1 week
and essay questions exams before schedule of
major exams
Lecture:2 major 80 % 98 % Conduct evaluation Conducted evaluation 8 8 8
examinations,8 quizzes effective effective measures as scheduled measures as scheduled
Recitations/class and needed and needed
participation
RLE: Actual observation, 2
major exams, 1 evaluation
exam and 2 quizzes/rotation,
2 case presentations/group ,
NCP/student, 1 journal
article
Submitted dully 80 % 100 % Submit DTR within 1 Submitted DTR within 6 8 8
accomplished PES, DTR effective effective week after the last day 1 week after the last
and10 grading sheets (2 of the month, PES as day of the month, PES
lecture, 4 RLE) scheduled, lecture as scheduled, lecture
grading sheets 1 week grading sheets 1 week
after major exam and after major exam and
RLE grading sheets 2 RLE grading sheets 2
days after each rotation days after each rotation
Supervised the class and Schedule meetings for Schedule meetings for 8 8 10
conduct 6 meetings; set 80% 100% planning 1 week before planning 1 week before
consultation hours ( 10 hours effective effective college and institute college and institute
a week or as needed) activities commence; activities commence;
sets 10:00am- 5:00pm sets 10:00am- 5:00pm
every Thursdays and every Thursdays and
Fridays as consultation Fridays as consultation
hours hours
III. OTHER ASSIGNMENTS
1. Attend faculty meeting and 6 8 8
seminars/trainings All faculty meetings and 1 Attended 6 faculty meetings 80 % 95 % As scheduled Present 15 minutes
seminar and 4 seminars effective effective before the assembly
2. Participate in school activities Madonna and Child Pinning Madonna and Child Pinning 80 % 95 % As scheduled Present 15 minutes 6 8 8
Ceremonies, Regional Ceremonies, Regional attended attended before the program
Quality Assurance Team Quality Assurance Team starts
Survey, Survey,
TOTAL: 94 1 04 96
GRAND TOTAL: 294
AVERAGE: 7.54
EQUIVALENT POINT SCORE: 5.28
I agree to achieve these targets for the rating period from November2010-March2011. I agree to assist the employee to achieve his target for the said period.

JOEFREY D. GAERLAN, RN, RM MAN
Instructor
Date:______________________
PART II. BEHAVIORAL DIMENSION (30%)
1. Courtesy ……………………..10
2. Human Behavior…………….. 10
3. Punctuality ………………….. 8
4. Initiative ……………………. 10
EMPLOYEE COMMENT/REPORTS
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REPORT RATER’S COMMENTS/ REMARKS
_______________________________________
_______________________________________
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NANCY ANN P. GONZALES, RN, MAN, Ph.D.
Name and Signature of Rater
Date:______________________
TOTAL: 38
Average Point Score: 9.5
Equivalent Point Score: 2.85
Overall Point Score: 8.13
Equivalent Adjectival Rating: Very Satisfactory
DISCUSSED RATING WITH:
___________________________________ __________________________________
___________________________________ Date
DISCUSSED RATING WITH:
_______________________________ ___________________________________
_______________________________ Date
_________________________________ ____________________________________
Signature of Rater’s Supervisor Date