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HomeMy WebLinkAbout2018-364-E Health - Piedmont Health Services dietitian servicesRevised 7/18 1 [Departmental Use Only] TITLE PHS - Dietitian FY 2018-2019 NORTH CAROLINA REGISTERED DIETITIAN SERVICES AGREEMENT ORANGE COUNTY This Services Agreement (hereinafter “Agreement”), made and entered into this 1st day of July, 2018, (“Effective Date”) by and between Orange County, North Carolina a body politic and corporate of the State of North Carolina (hereinafter, the "County") through their Department of Health (hereinafter, the “OCHD”) and Piedmont Health Services, Inc, (hereinafter, the "PHS"). WITNESSETH: That the County and PHS, for the consideration herein named, do hereby agree as follows: 1. Services a. Scope of Work. i) This Agreement is for services to be rendered by the County to PHS with respect to: Twenty hours (20) per week services of a North Carolina licensed Registered Dietitian (“RD”), as provided in the attached Exhibit 1, PHS Job Description (WIC Nutritionist) and Section 3 below, Basic Services. ii) By executing this Agreement, the County represents and agrees that OCHD is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner. iii) Time is of the essence with respect to this Agreement. iv) The services to be performed under this Agreement consist of Basic Services, as described and designated in Section 3 hereof and as provided in Exhibit 1, PHS Job Description. Compensation to the County for Basic Services under this Agreement shall be as set forth herein. 2. Responsibilities of PHS a. Services to be provided. The County shall provide PHS with all services required in Section 3 to satisfactorily complete the Project within the time limitations set forth herein and in accordance with the highest professional standards. b. Standard of Care. i) The County shall exercise reasonable care and diligence in performing services under this Agreement in accordance with the highest generally accepted standards of this type of practice throughout the United States and in accordance with DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 2 applicable federal, state and local laws and regulations applicable to the performance of these services. County is solely responsible for the professional quality, accuracy and timely completion and/or submission of all work related to the Basic Services. ii) The County shall be responsible for all errors or omissions, in the performance of the Agreement. The County shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the PHS. iii) The County shall not, except as otherwise provided for in this Agreement, subcontract the performance of any work under this Agreement without prior written permission of PHS. No permission for subcontracting shall create, between the PHS and the subcontractor, any contract or any other relationship. iv) The County is an independent contractor of PHS. Any and all employees of the County engaged by the County in the performance of any work or services required of the County under this Agreement, shall be considered employees or agents of the County only and not of PHS, and any and all claims that may or might arise under any workers compensation or other law or contract on behalf of said employees while so engaged shall be the sole obligation and responsibility of the County. v) The County agrees that its employees, agents and its subcontractors, if any, shall be required to comply with all federal, state and local antidiscrimination laws, regulations and policies that relate to the performance of County’s services under this Agreement. vi) If activities related to the performance of this Agreement require specific licenses, certifications, or related credentials County represents that it and/or its employees, agents and subcontractors engaged in such activities possess such licenses, certifications, or credentials and that such licenses certifications, or credentials are current, active, and not in a state of suspension or revocation. 3. Basic Services a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows (fully describe services to be provided): Twenty hours per week services of a Registered Dietitian as provided in accordance with the attached Exhibit 1 PHS Job Description, WIC Nutritionist, and this Section of the Agreement as provided below: i) Hiring Responsibility: (a) OCHD will conduct the recruitment process; however, the PHS shall review and contribute to the job posting; (b) All job applications must follow the Orange County and OCHD hiring and recruitment policies; (c) The position will be posted on the Orange County job vacancy website. PHS may create a link to the Orange County vacancy website to advertise the position; DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 3 (d) PHS will collaborate with OCHD in the selection process by helping to develop interview questions and serving on the interview and selection panel. ii) Job Description: The person in the position will follow the duties described within the Orange County job description when working with OCHD. While working at PHS, the person will follow the job duties as described in the PHS job description for WIC Nutritionist (Exhibit 1). Job duties will be consistent with the scope of practice for dietitians registered and licensed to practice in North Carolina. iii) Supervision: OCHD Nutrition Program Manager is the primary supervisor of the RD. However, PHS will provide on-site supervision of the dietitian for the 20 hours per week the person works at PHS. PHS will report any practice infractions to OCHD within twenty-four hours. PHS will work with OCHD to create WPPR performance measures and consult with OCHD on the annual performance review. Supervisors will communicate monthly. iv) Orientation/Training: The RD must attend any County, OCHD and PHS required orientation and training. OCHD and PHS will discuss training needs and requirements and develop a mutually agreed upon schedule to meet the requirements. The contracted dietitian will be trained and proficient in the WIC Nutritionist role in Crossroads. Training and Orientation may cause the normal work schedule to vary. v) Policies/Procedures: The RD shall abide by the rules, policies, and procedures of PHS in the performance of all services provided under this Agreement (which shall include, but not be limited to, clinical policies, procedures, and protocols; HIPAA privacy and security policies; quality assurance standards; standards of conduct; and grievance and complaint resolution procedures, as amended from time to time) and shall fully cooperate with PHS, as reasonably requested in PHS’ quality improvement processes, as well as implementing PHS’ corporate compliance program or other regulatory certification or accreditation program. PHS shall provide the RD a copy of all PHS rules, policies, and procedures the RD is expected to abide prior to the RD commencing performance of the services provided under this Agreement. vi) Probationary Period: OCHD has a statutorily required 24 month probationary period to assess if the employee can perform proficiently. During this period of time, the Orange County Health Director has the right to terminate the employment due to unsatisfactory performance. Since this employee will be employed by OCHD, this would supersede the 90-day probationary period normally applied to PHS employees. Termination of the RD employment will terminate this Agreement. vii) Any revenue generated by the RD at PHS while providing the twenty hours of service shall be the property of PHS. viii) PHS assumes responsibility for setting fees, billing, collections and dispute resolutions for RD services provided at the PHS site. DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 4 4. Duration of Services a. Term. The term of this Agreement shall be from July 1, 2018to June 30, 2019. b. Scheduling of Services. i) Regular Schedule. The RD shall work at OCHD on Tuesday and Thursday (8am to 4:30pm) and Fridays (all day). The RD shall work at PHS on Mondays (8am to 5pm) and Wednesdays (8am to 5pm) and Thursday (5pm to 8pm), any changes to regular schedule or location of the RD will be made by the PHS Supervisor and the OCHD Nutrition Program Manager. Schedule or location changes must be mutually agreed upon by both parties in writing. ii) Excess Time Worked. Any time worked over the twenty hours per week required under this Agreement shall be paid by PHS. iii) Holiday Schedule. The RD will follow the holiday schedule adopted by the Orange County Board of County Commissioners for County employees. If PHS requires the RD to work during a scheduled holiday, PHS will be responsible for any overtime or holiday pay. iv) Leave. The RD will be provided with vacation and sick leave as an Orange County employee. When the employee is on scheduled leave from Orange County and PHS, PHS will be required to pay for services when the RD is on approved leave. The OCHD Nutrition Program Manager will consult with the PHS Supervisor prior to approving employee requests for vacation and sick leave. v) The Commencement Date for Basic Services shall be July 1, 2018. 5. Compensation a. Compensation for Basic Services. Compensation for Basic Services shall include all compensation due to the County from PHS for all services under this Agreement. The maximum amount payable for Basic Services shall not exceed a total of Thirty Five Thousand Four Hundred Twenty Seven and 50/100 Dollars ($35,427.50) exclusive of any overtime or holiday pay. Mileage reimbursement shall only be paid when the RD is working at a location that is not part of the regularly assigned schedule. Mileage will be reimbursed at the then-current IRS rate (currently 54.5 cents) per mile for a maximum of 100 miles ($54.50). Payment for Basic Services shall become due and payable within thirty (30) days of the County properly invoicing PHS. The County shall invoice PHS monthly. Payment shall be subject to provisions of Section 5(b). Payment will begin only after the employee has been hired to the position and has begun receiving compensation from the County. b. Disputes. In the event the amount stated on an invoice is disputed by the PHS, PHS may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. Should the County fail to perform its duties under the terms of this Agreement, PHS may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 5 c. Additional Services. PHS shall not be responsible for costs related to any services in addition to the Basic Services performed by County unless County requests such additional services in writing and such additional services are evidenced by a written amendment to this Agreement. 6. Responsibilities of the County a. Cooperation and Coordination. The County has designated Renee Kemske to act as the County's representative with respect to Agreement and shall have the authority to render decisions within guidelines established by the Health Director and/or the County Board of Health and shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance a. General Requirements. PHS shall purchase and maintain and shall cause each of his subcontractors to purchase and maintain, during the period of performance of this Agreement: i) Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the PHS's employees or any other person and to real and personal property including loss of use resulting thereof in the amount of at least $ 1,000,000 for each occurrence and $2,000,00 in the aggregate; b. Additional Insured. All insurance policies required under this Agreement shall name the County as an additional insured party. Evidence of such insurance shall be furnished to the County, together with evidence that each policy provides the County with not less than thirty (30) days prior written notice of any cancellation, non-renewal or reduction of coverage. 8. Indemnity a. Indemnity. PHS agrees to defend, indemnify and hold harmless the County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the Agreement and arising from bodily injury including death or property damage to any person or persons caused in whole or in part by the negligence or misconduct of PHS except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this provision to require the PHS to indemnify the County to the fullest extent permitted under North Carolina law. 9. Amendments to the Agreement a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional compensation or a change in duration of this Agreement shall be made by a written Amendment to this Agreement executed by the County and the PHS. The County shall proceed to perform the Services required by the Amendment only after receiving a fully executed Amendment from PHS. DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 6 10. Termination a. Termination for Convenience of the County. This Agreement may be terminated without cause by the County and for its convenience upon seven (7) days’ prior written notice to the PHS. b. Other Termination. PHS may terminate this Agreement based upon the County's material breach of this Agreement provided the County has not taken all reasonable actions to remedy the breach. PHS shall give the County thirty (30) days' prior written notice of its intent to terminate this Agreement for cause. c. Compensation After Termination. i) In the event of termination, the County shall be paid that portion of the fees and expenses that the employee has earned to the date of termination. ii) Should this Agreement be terminated, the County shall deliver to PHS within thirty (30) days, at no additional cost, all deliverables including any electronic data or files relating to this Agreement. d. Waiver. The continuation of services by the County under this Agreement or the failure of the County to require compliance by the PHS with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 11. Additional Provisions a. Limitation and Assignment. The County and the PHS each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the PHS shall assign or transfer its interest in this Agreement without the written consent of the other. b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorp orated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147- DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 7 86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. c. Confidentiality of Patient Records. All parties agree to abide by all laws and regulations governing the confidentiality of patient information, including HIPAA privacy rules and further agree to vigorously safeguard privileged information. d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. The Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. e. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the PHS and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. f. Severability. If any provision of this Agreement is held as a matter of law to be unenforceable, the remainder of this Agreement shall be valid and binding upon the Parties. g. Non-Appropriation. PHS acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County’s obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to PHS of the unavailability and non-appropriation of public funds. It is expressly agreed that County shall not activate this non-appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the County’s statutory authority, mandate and/or mandated functions, by state and/or federal legislative or regulatory action, which adversely affects County’s authority to continue its obligations under this Agreement, then this Agreement shall automatically terminate without penalty to County upon written notice to PHS of such limitation or change in County’s legal authority. h. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Piedmont Health Services, Inc. Attention: Kimberlee Quatrone Attention: Brian Toomey P.O. Box 8181 127 Kingston Drive DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 8 Hillsborough, NC 27278 Chapel Hill, NC 27514 i. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. j. Priority: In determining the basic services to be provided, should any documents be referenced in this Agreement, the terms herein shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement, except the Business Associate Agreement. k. Records Access and Retention. The contractor agrees that the state, USDA, the Comptroller General of the United States, or any of their duly authorized representatives, shall have access to any books documents, papers, and records of the contractor which are directly pertinent to that specific contract, for the purpose of making audit, examination, excerpts, and transcriptions. The contractors shall maintain all required records for the period specified in the North Caro lina Department of Health and Human Resources Records Retention and Disposition Schedule for Local Health Departments, http://www.records.ncdcr.gov/local/county_health/health_Department_2007.pdf. l. Title VI and WIC Policy. All activities under this contract will be conducted in accordance with Title VI, Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and WIC Program rules, regulations and policies. No person shall, on the grounds of race, color, creed, marital status, national origin, political beliefs, sex or handicap be submitted to discrimination under the Program. [SIGNATURE PAGE TO FOLLOW] DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C Revised 7/18 9 IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PHS: By: _________________________________ Bonnie Hammersley , County Manager By: __________________________________ Brian Toomey, Executive Director DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 1 Piedmont Health Services Performance Evaluation/Job Description Name: WIC Nutritionist Reports to: Lead Nutritionist FLSA Status: OSHA Category: Review Period:_______________________ Type of Evaluation: ___________________ JOB SUMMARY Performs a variety of responsible tasks involving counseling of individuals and families in nutrition principals, diet, food selection, and economics for the WIC Program. MINIMUM QUALIFICATIONS Education: Bachelors degree from an accredited college or university in Nutrition, Public Health Nutrition or Dietetics Current/valid License: N/A Experience: One year of public health experience or similar preferred. PATIENT POPULATION SERVED Ethnically and racially diverse population of pregnant, breastfeeding, postpartum women, infants and young children and all family members involved. PHYSICAL DEMANDS/ WORKING CONDITIONS Requires frequent sitting for long periods, operation of standard office machines and computer. May require lifting of up to 25 pounds. Requires hand-eye coordination and manual dexterity. Requires use of office equipment, such as computer terminals, telephones or copiers. Requires normal vision range. Work is performed in an office environment. Contact with staff and external clients and vendors. Revised: September 2014 Exhibit 1 DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 2 RESPONSIBILITIES AND DUTIES Be l o w St a n d a r d Ne e d s Im p r o v e m e n t Me e t s Ex p e c t a t i o n s Ex c e e d s Ex p e c t a t i o n s 1. Patient Care: Determine WIC Program eligibility based on the medical and nutrition risk identified. Determines risk codes, based on assessment and information presented. Provides individualized counseling in nutrition and breastfeeding based on needs and resources identified above. Consults with medical providers, social work and other healthcare providers as needed to provide optimal care. Conducts counseling in culturally appropriate way to meet the needs of the patients. Screens immunization records of clients and makes referral as appropriate. Based on professional discretion determines follow schedule for patient Communicates with medical providers as needed Defers to lead nutritionist or RD for additional guidance with patients Demonstrates the ability to work with diverse patient populations served Competency Validation: 1 2 3 4 Comments: DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 3 RESPONSIBILITIES AND DUTIES Be l o w St a n d a r d Ne e d s Im pr o v e m e n t Me e t s Ex p e c t a t i o n s Ex c e e d s Ex p e c t a t i o n s 2. Quality Control/Safety: Prescribes or reviews food package to determine adequacy. Completes WIC certifications Evaluates all prescriptions for special and therapeutic formula Helps to ensure a safe environment in clinic with staff and clients. Competency Validation: 1 2 3 4 Comments: 3. Patient Education: Asks open-ended questions to obtain additional information. Provides thorough assessment of each patient and determine appropriate risk code Based on client centered approach, determines educations topic. Effectively presents education topic with appropriate handouts. Determines correct follow-up visit based on risk code. Documents nutrition education contacts. Interprets, evaluates, and utilizes pertinent current research relating to nutrition care. Assists in the development and selection nutrition education materials for use by clients. Assists in outreach activities. Competency Validation: 1 2 3 4 DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 4 Comments: Nasim is eager about increasing ca RESPONSIBILITIES AND DUTIES Be l o w St a n d a r d Ne e d s Im p r o v e m e n t Me e t s Ex p e c t a t i o n s Ex c e e d s Ex p e c t a t i o n s 4. Procedure Execution: Reviews chart notes, past visits prior to meeting with patient Performs anthropometric measurements as needed per standards in the WIC Local Policy and Procedures Manual and State WIC Policy and Procedures Manual Follows all procedures and policies as outlined by the WIC local and state Policy and Procedure Manuals Competency Validation: 1 2 3 4 Comments: 5. Administrative Duties Assists in ordering of supplies such as State WIC, and free materials. Assists in problem solving and making recommendations concerning issues pertinent to the WIC Program guidelines within local agency. Assists in training of new staff members and interns Assists in the performance of other administrative duties in relationship to the WIC Program. In the absence of the lead nutritionist, functions as supervisor on a interim basis Competency Validation: 1 2 3 4 DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 5 Comments: UNIVERSAL PERFORMANCE STANDARDS Be l o w S t a n d a r d Ne e d s Im p r o v e m e n t Me e t s Ex p e c t a t i o n s Ex c e e d s Ex p e c t a t i o n s 6. Customer Service (Internal and External Customers) Demonstrates concern for the rights, privacy and confidentiality of patients and others Understands the urgency of customer needs and responds quickly Treats all patients in accordance with the Patient’s Bill of Rights Considers the impact on patients, visitors and peers when taking action and carrying out one’s own job tasks Anticipates the needs of patients, visitors, providers and peers and assists them in a helpful, positive manner Seeks to solve problems for patients and their families and offers assistance and encouragement to others Communicates with patients/families, visitors and coworkers in a courteous and respectful manner Demonstrates effective communication recognizing diversity among age groups, cultures, and educational levels Competency Validation: 1 2 3 4 Comments: 7. Teamwork Consistently works in a positive and cooperative manner with other employees in and outside of departmental unit Values and incorporates the contributions of people from diverse backgrounds; demonstrates respect for the opinions and ideas of others Assist in training and orientation of new staff Shares information and own expertise with others to enable them to accomplish goals and objectives Seeks out opportunities to help rather than waiting to be asked Assist other team members in the performance of their assignment DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 6 Competency Validation: 1 2 3 4 Comments: UNIVERSAL PERFORMANCE STANDARDS Be l o w St a n d a r d Nee d s Im p r o v e m e n t Me e t s Ex p e c t a t i o n s Ex c e e d s Ex p e c t a t i o n s 8. Professional Conduct Maintains professional demeanor in all interactions with patients and staff Functions independently and completes assignments with minimal supervision Adapts to changes in the work environment Maintains acceptable attendance record Observes work schedule by being punctual for shift, observing designated break schedule, and not leaving work area while on duty Adheres to all applicable Center and department rules, policies and procedures Participates in continuing education , in-services, staff development and meetings Has completed annual retraining Responds positively to constructive criticism from peers and supervisors Competency Validation: 1 2 3 4 Comments: DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 7 UNIVERSAL PERFORMANCE STANDARDS Be l o w S t a n d a r d Ne e d s Im p r o v e m e n t Me e t s Ex p e c t a ti o n s Ex c e e d s Ex p e c t a t i o n s 9. Efficiency Completes work in an organized and timely manner Prioritizes and plans work activities to achieve maximum efficiency Meets productivity standards Strives to improve productivity Minimize non-productive time by filling slow periods with activities such as assisting others, professional development and education, organization of work area, housekeeping, etc. Organize job functions and work area to effectively complete assignments Manage resources efficiently and works to reduce costs and improve quality Competency Validation: 1 2 3 4 Comments: 10. Quality of Work /Problem Solving Demonstrates commitment to excellence by consistently looking for ways to improve and promote quality Identifies problems in a timely manner and develops alternative solutions to problems Contribute to Continuous Quality Improvement activities Reports to appropriate person any conflicting cultural values, ethics, or religious beliefs that may impact patient care Consistently evaluates work and evaluate if further steps are needed to meet customer/patient/management expectations Demonstrates sound judgment by taking appropriate actions regarding questionable findings or concerns Competency Validation: 1 2 3 4 DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 8 Comments: Performance Category Overall Performance Category for this review period: ____________Exceeds Expectation (An employee consistently exceeds all performance expectations for this period.) ____________Meets Expectations (An employee in this category has met all areas of expectations and effectively demonstrated relevant competencies.) ____________Needs Improvement (Performance that is acceptable is some, but not all aspects of the job and does not consistently meet basic position requirements.) Next Review will be conducted on _____________ Summary / Areas for Improvement DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C 9 Signature Page Employee Comments: Employee Signature I have received a written and verbal Performance Review. My signature does not indicate agreement or disagreement with this review. Employee Signature________________________________Department________________________ Date _____ Supervisor Signature I have written and delivered a performance Review for this employee: Supervisor Signature________________________________ Position_________________________ Date____________________ Executive Director Signature________________________________ Date _____ DocuSign Envelope ID: 1F50F7AE-561F-49AE-AF6E-02EC3D46985C