Republic of the Philippines

Department of Health
Regional Field Office No. 3
JOSE B. LINGAD MEMORIAL GENERAL HOSPITAL
City of San Fernando, Pampanga
INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR)

I,Crizaldy John D. Galvan, of the Pediatric Department commit to deliver and agree to be rated on the attainement of the following targets in accordance with the indicated measures for the period of January to June, 2021.

Equivalent Weight of Ouput

Functions Strategic Core Support Crizldy John D. Galvan, RN
Weight 30% 40% 30% Ratee Name

Approved by Date
Sheryl M. Sampang, RN
January 01,2021
Name of Supervisor
5 – Outstanding
4 – Very Satisfactory
3 – Satisfactory
2 - Unsatisfactory
1 - Poor

Major Final Output/ Rating

Success Indicators
Program, Activity & Actual Accomplishments (d) Remarks
(Targets + Measures)
Project/Deliverable (c) (e)
(b) Q 1
E 2
T 3
A 4
(a)
A.Strategic Functions (30%)

4.00 NA NA 4.00

5.00 NA NA 5.00

Sub-Total for Strategic Functions (30 %) 4.50

B. Core Functions: (40%)

80% evaluation of staffs thru daily

Grading of scorecard 4.00 NA NA 4.00
accomplishment scorecards by the end of 2021.
 Major Final Output/ Rating
Success Indicators
Program, Activity & Actual Accomplishments (d) Remarks
(Targets + Measures)
Project/Deliverable (c) (e)
(b) Q1 E2 T3 A4
(a)

Staff Coaching/ Mentoring 80% guidance of staffs who needs improvement

3.00 NA NA 3.00
by the end of 2021.

80% compliance in submission of schedule on

Semi Monthly Schedule 4.00 NA NA 4.00
time by the end of 2021.

Sub-Total for Core Functions (40 %) 3.67

C. Support Functions: (30 %)

80% accomplishment of checklist for chart

Chart Audit completion form before submission to HIMS by 5.00 NA NA 5.00
the end of 2021.

80% accomplishment of donning/ doffing

Quality Indicator Checklist 4.00 NA NA 4.00
checklist by the end of 2021.

80% attachment of signature to the controlled

drugs administration sheet and requisition for
Regulated Drugs dangerous drug preparation or drug preparation 4.00 NA NA 4.00
containing controlled chemical for patient use by
the end of 2021.

Sub-Total for Support Functions (30 %) 4.33

RATING
Total over all rating 4.11667
Final Average Rating 4.12
Adjectival Rating VS
Comments and Recommendation for Development Purposes:
Demostrates the ability to work under pressure and to plan and organize successfuly to meet tight deadlines.

Discussed With: Assessed by: Date Final Rating by: Date

I certify that I discussed my assessment of the perfomance with the
employee
Crizaldy John D. Galvan, RN Sheryl M. Sampang, RN July 16, 2021 Mr. Edwin C. Maniago, RN July 16, 2021
Employee Supervisor Next Higher Supervisor
Legend: 1- Quality 2 -Efficiency 3 - Timeliness 4 - Average

ISO CERTIFIED HOSPITAL - QUALITY MANAGEMENT SYSTEM

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strictly prohibited unless otherwise permitted by JBLMGH Top Management