KP IT TALENT ACQUISITION

CANDIDATE INTERVIEW EVALUATION FORM

Position Title:
Candidates Name:

Interviewers Name:
Interview Date: XX/XX/2010

PLEASE COMPLETE BOTH PAGES OF THIS FORM IMMEDIATELY AFTER YOUR

INTERVIEW AND FORWARD TO DICK FEARN VIA EMAIL (PREFERRED) OR FAX TO
626-564-3051. THANK YOU FOR YOUR PARTICIPATION.

Technical/Job Skills

Rating*

Job Requirements

Technical Competence

Relevant Skills

Relevant Prior Work Experience

Relevant Scope/Scale Experience

* 5 Excellent, 4 Above Average, 3 Average, 2 Below Average,

N/A Did not evaluate (leave blank)

1 Did not demonstrate

Core Behaviors

Rating*

Focus On The Customer

Collaborates

Takes Accountability

Drives For Results

Communicates Effectively

Champions Innovation & Change

Develops Self & Others

* 5 Excellent, 4 Above Average, 3 Average, 2 Below Average,

N/A Did not evaluate (leave blank)

1 Did not demonstrate

Menu Behaviors

Rating*

Thinks & Acts Strategically

Exerts Influence

Business Acumen

Makes Effective Decisions

Solves Problems Through Planning & Analysis

Leverages Technology

Demonstrates Resource Stewardship

Demonstrates Creativity

Pays Attention To Detail

Deals With Ambiguity

* 5 Excellent, 4 Above Average, 3 Average, 2 Below Average,

N/A Did not evaluate (leave blank)

1 Did not demonstrate

KP IT TALENT ACQUISITION
CANDIDATE INTERVIEW RATING FORM
Page 2

Additional Observations/Comments/Notes:

Summary Recommendation:
Would you recommend the hiring of this candidate for this position?
Strong Candidate
+++

(Please check one block)

Good Candidate
++

Borderline Candidate
+/-

Would Not Recommend

--

Would you recommend the hiring of this candidate for other positions within KP IT?
Strong Candidate
+++

Good Candidate
++

Borderline Candidate
+/-

Would Not Recommend

--

(Please check one block)

CONFIDENTIAL
This Candidate Interview Rating Form was prepared by KP-IT Talent Acquisition and once, completed by the
Interviewer, is confidential. This information should be restricted only to those KP-IT employees designated as
participants for this particular search and is intended for internal use only. Kaiser Permanente is proud to be an
EOE/AA employer.