ࡱ> bdaY  &bjbjWW %`==](((((Dlt("2.222J K O !!!!!!!$#%l! 9 ^ !k2Jkkk 2J!(( !kk2!h!2$ȕ>m((!State of New York PERFORMANCE EVALUATION APPEALS FORM This form is for use by Management/Confidential employees and employees in the following bargaining units who wish to appeal a rating of Unsatisfactory: Professional, Scientific and Technical unit represented by PEF; Administrative Services, Operational Services, Institutional Services and Division of Military and Naval Affairs units represented by CSEA; and Rent Regulation Services unit represented by DC-37. _________________________________________________________________________________________________________ Please print or type Unit (check one):  FORMCHECKBOX  Management/Confidential  FORMCHECKBOX  Professional, Scientific and Technical Services  FORMCHECKBOX  Administrative Service  FORMCHECKBOX  Institutional Services  FORMCHECKBOX  Rent Regulation Services  FORMCHECKBOX  Operational Services  FORMCHECKBOX  DMNA Your Name FORMTEXT      Social Security No. FORMTEXT       Agency FORMTEXT      Facility/Division FORMTEXT       Item No. FORMTEXT      Title FORMTEXT       Name of Supervisor FORMTEXT      Name of Reviewer FORMTEXT       Date Rating Received FORMTEXT      Evaluation PeriodFrom FORMTEXT      To FORMTEXT       You may seek to have your "Unsatisfactory" rating raised to the next higher rating category and you have 15 calendar days from the date you receive your rating to file an appeal. The first step will be a review of your appeal by your Agency Performance Evaluation Appeals Board (STEP 1 below). __________________________________________________________________________________________________________ STEP 1 - AGENCY LEVEL Instructions To appeal your "Unsatisfactory" rating, complete this form in the space provided below and submit it to your Agency Appeals Board. Unless you cite specific reasons why your work performance deserves a higher rating, your appeal will be dismissed. Only your rating may be appealed. Disputes concerning such issues as your individual performance program and the rating and appeals process are not subject to appeal. Employees who appeal their rating may make a personal appearance before their Agency Appeals Board to explain their reasons for appeal. If you wish to make a personal appearance, you must indicate this by checking the box below. CSEA-, PEF- and DC-37-represented employees are entitled to be accompanied by a representative appointed by their respective unions. M/C-designated employees may be accompanied by a person of their choosing who may act as an observer only. Reasons for Appeal:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       (Attach additional sheets, if necessary)  FORMCHECKBOX  I request a personal appearance before the Agency Appeals Board Employee SignatureDate Submitted FORMTEXT        AGENCY APPEALS BOARD RECOMMENDED DECISION Date Request Received by Agency Appeals Board FORMTEXT       The appeal of the above-named employee has been received and we recommend that the appeal be:  FORMCHECKBOX  Sustained  FORMCHECKBOX  Denied SignedDate FORMTEXT       AGENCY APPEALS BOARD SUMMARY STATEMENT The following statement summarizes the basis for our recommended decision: (Attach additional sheets, if necessary)  AGENCY HEAD DECISION I have reviewed the recommendation of the Agency Board. Your appeal is:  FORMCHECKBOX  Sustained  FORMCHECKBOX Denied Signed Agency Head or DesigneeDate Issued FORMTEXT       STEP 2 - STATEWIDE LEVEL Instructions If your appeal has been denied at the agency level, you have 15 calendar days from the date you receive the agency level decision to appeal to the Statewide Performance Evaluation Appeals Board. To do so, complete this form in the space provided below. Attach legible copies of your performance program and evaluation forms, worksheets, and any other pertinent documents. Employees must send these documents by Certified Mail - Return Receipt Requested to the Statewide Performance Evaluation Appeals Board, c/o Governor's Office of Employee Relations, 2 Empire State Plaza, Suite 1201, Albany, NY 12223-1250. You must provide reasons for your disagreement with the agency level decision, and sign and date the form where indicated. You must also send a copy of this Appeals Form to your Agency Personnel Office. Employees (with the exception of Management/Confidential employees for whom the Statewide Appeals Board's decision is based solely upon a review of the record) are entitled to appear before the Statewide Appeals Board to explain their reasons for disagreement with the agency level decision. If you wish to do so you must indicate this by checking the box below. CSEA-, PEF- and DC-37-represented employees are entitled to be accompanied by a representative appointed by their respective unions. Reasons for Disagreement with STEP 1 - AGENCY LEVEL decision:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       (Attach additional sheets, if necessary)  FORMCHECKBOX  I request a personal appearance before the Statewide Appeals Board (PS&T, ASU, ISU, OSU, DMNA, RRSU only) Employee SignatureDate Submitted FORMTEXT       Mailing Address FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      StreetCityStateZip Code Home Telephone(  FORMTEXT     ) FORMTEXT      Work Telephone( FORMTEXT     ) FORMTEXT       Area CodeNumber Area CodeNumber  STATEWIDE APPEALS BOARD DECISION Date Request Received by Statewide Appeals Board FORMTEXT       The Statewide Appeals Board has reviewed your appeal. It has:  FORMCHECKBOX  Sustained  FORMCHECKBOX  Denied your appeal. 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