PT. XYZ Jl.

Istana Merdeka
Jakarta

PERFORMANCE EVALUATION SHEET

Employee's Data 1st Evaluator (Direct Supervisor) : Accounting Manager Grade :

Name Mr./Ms. X 2nd Evaluator (Work Colleague) : Chief of Finance 5 = Very good
Position Chief of Accounting 3rd Evaluator (Direct Subordinate) : Accounting Staff 3 = Sufficient
Department Finance, Accounting & Tax Evaluation Period : 12 months 1 = Lacking
Working Period 12 months Date of Evaluation :Dec 2012

Weight 1st Evaluator (50%) 2nd Evaluator (30%) 3rd Evaluator (20%) Final Grade :
Evaluation Criteria
G GxB G GxB G GxB Exceptional = 18< x <20
1 Work Quality 1 5 5 5 5 5 5 Excellent = 16< x <18
2 Dutifulness 1 5 5 5 5 5 5 Good = 14< x <16
3 Team work 1 5 5 5 5 5 5 Average = 12< x <14
4 Initiative 1 5 5 5 5 5 5 Insufficient = below 12
TOTAL 4 Sub Total 1 20 Sub Total 1 20 Sub Total 2 20

Attendance and Discipline (filled by HRD) Score : [Sub Total 1 x50%] + [Sub Total 2 x 30%]+[Sub Total 1 x20%]

Overdue Sick leave Permit

Score = 10 6 4 = 20

1 x ……… days 3 x .…… days 5 x .…… days Final Grade: Score -- Attandance deduction

Absence Warning letter Memoranda Exceptional 20

15 x ……… days (- 30)/letter (- 50)/memoranda
0 0 0
 PT. SANIMARDANI RESOURCES
Kampung Gunung Sari, Kecamatan Segah

Berau - Kalimantan Timur

FORM PENILAIAN KINERJA TAHUNAN

IDENTITAS PEKERJA PENILAI 1 (Atasan Langsung) Grade : Final Grade :

Nama PENILAI 2 (Camp Manager) 5 = Sangat baik A = 421 - 500
Jabatan PENILAI 3 (Kepala Operasional) 4 = Baik B = 341 - 420
Dept. Periode Penilaian 3 = Cukup C = 261 - 340
Masa kerja Tanggal Penilaian 2 = Kurang D = < 261

Bobot Penilai 1 (50%) Penilai 2 (30%) Penilai 3 (20%) Ttd Penilai 1 Ttd Penilai 2
KRITERIA PENILAIAN B G GxB G GxB G GxB
1 Kualitas Kerja 25 4 100 5 125 4 100
2 Kepatuhan 25 4 100 5 125 4 100
3 Kerjasama / Team Work 25 4 100 5 125 4 100
4 Inisiatif 25 5 125 5 125 4 100 Ttd Penilai 3
JUMLAH 100 Sub Total 1 425 Sub Total 1 500 Sub Total 2 400
PENILAIAN ABSENSI & DISIPLIN Score : [Sub Total 1 x50%] + [Sub Total 2 x 30%]+[Sub Total 3 x20%]

Ijin ( -5/Hari )
Surat Teguran Score = 212.5 150 80 = 442.5
( -30/Kali )

0 hari 0 kali Final Grade / NILAI AKHIR : Score -- Potongan Absensi Catatan :
0 0 Pekerja yang mendapat Surat
Mangkir ( -15/ Hari )
Surat Peringatan
( -50/Kali )
A 442.5 Peringatan tidak berhak mendapat Final
Grade "B"
0 hari 0 kali
0 0
 PT. SANIMARDANI RESOURCES
Kampung Gunung Sari, Kecamatan Segah

Berau - Kalimantan Timur

FORM PENILAIAN KINERJA TAHUNAN

IDENTITAS PEKERJA PENILAI 1 (Kepala Operasioal) : Dodi Kurnaedi Grade : Final Grade :
Nama Feri Efendi PENILAI 2 (Camp Manager) : Suryadi A. Mentemas 5 = Sangat baik A = 421 - 500
Jabatan Kabag. Pers. & Keuangan PENILAI 3 (Kasie/Staff) : 4 = Baik B = 341 - 420
Dept. Administrasi & Pelayanan Periode Penilaian : 1 Tahun (Jan - Des 2023) 3 = Cukup C = 261 - 340
Masa kerja 8 Bulan / 08 Agustus 2022 Tanggal Penilaian : 01 Maret 2023 2 = Kurang D = < 261

Bobot Penilai 1 (50%) Penilai 2 (30%) Penilai 3 (20%) Ttd Penilai 1 Ttd Penilai 2
KRITERIA PENILAIAN B G GxB G GxB G GxB
1 Kualitas Kerja 25 1 25 4 100 4 100
2 Kepatuhan 25 1 25 4 100 4 100
3 Kerjasama / Team Work 25 1 25 4 100 4 100
4 Inisiatif 25 1 25 4 100 4 100 Ttd Penilai 3
JUMLAH 100 Sub Total 1 100 Sub Total 1 400 Sub Total 2 400
PENILAIAN ABSENSI & DISIPLIN Score : [Sub Total 1 x50%] + [Sub Total 2 x 30%]+[Sub Total 3 x20%]

Ijin ( -5/Hari )
Surat Teguran Score = 50 120 80 = 250
( -30/Kali )

0 hari 0 kali Final Grade / NILAI AKHIR : Score -- Potongan Absensi Catatan :
0 0 Pekerja yang mendapat Surat
Mangkir ( -15/ Hari )
Surat Peringatan
( -50/Kali )
D 250 Peringatan tidak berhak mendapat Final
Grade "B"
0 hari 0 kali
0 0
 500 A
499.5 A
499 A
498.5 A
498 A
497.5 A
497 A
496.5 A
496 A
495.5 A
495 A
494.5 A
494 A
493.5 A
493 A
492.5 A
492 A
491.5 A
491 A
490.5 A
490 A
489.5 A
489 A
488.5 A
488 A
487.5 A
487 A
486.5 A
486 A
485.5 A
485 A
484.5 A
484 A
483.5 A
483 A
482.5 A
482 A
481.5 A
481 A
480.5 A
480 A
479.5 A
479 A
478.5 A
478 A
477.5 A
477 A
476.5 A
476 A
475.5 A
475 A
474.5 A
474 A
473.5 A
473 A
472.5 A
472 A
471.5 A
471 A
470.5 A
470 A
469.5 A
469 A
468.5 A
468 A
467.5 A
467 A
466.5 A
466 A
465.5 A
465 A
464.5 A
464 A
463.5 A
463 A
462.5 A
462 A
461.5 A
461 A
460.5 A
460 A
459.5 A
459 A
458.5 A
458 A
457.5 A
457 A
456.5 A
456 A
455.5 A
455 A
454.5 A
454 A
453.5 A
453 A
452.5 A
452 A
451.5 A
451 A
450.5 A
450 A
449.5 A
449 A
448.5 A
448 A
447.5 A
 447 A
446.5 A
446 A
445.5 A
445 A
444.5 A
444 A
443.5 A
443 A
442.5 A
442 A
441.5 A
441 A
440.5 A
440 A
439.5 A
439 A
438.5 A
438 A
437.5 A
437 A
436.5 A
436 A
435.5 A
435 A
434.5 A
434 A
433.5 A
433 A
432.5 A
432 A
431.5 A
431 A
430.5 A
430 A
429.5 A
429 A
428.5 A
428 A
427.5 A
427 A
426.5 A
426 A
425.5 A
425 A
424.5 A
424 A
423.5 A
423 A
422.5 A
422 A
421.5 A
421 A
420.5 B
420 B
419.5 B
419 B
418.5 B
418 B
417.5 B
417 B
416.5 B
416 B
415.5 B
415 B
414.5 B
414 B
413.5 B
413 B
412.5 B
412 B
411.5 B
411 B
410.5 B
410 B
409.5 B
409 B
408.5 B
408 B
407.5 B
407 B
406.5 B
406 B
405.5 B
405 B
404.5 B
404 B
403.5 B
403 B
402.5 B
402 B
401.5 B
401 B
400.5 B
400 B
399.5 B
399 B
398.5 B
398 B
397.5 B
397 B
396.5 B
396 B
395.5 B
395 B
394.5 B
 394 B
393.5 B
393 B
392.5 B
392 B
391.5 B
391 B
390.5 B
390 B
389.5 B
389 B
388.5 B
388 B
387.5 B
387 B
386.5 B
386 B
385.5 B
385 B
384.5 B
384 B
383.5 B
383 B
382.5 B
382 B
381.5 B
381 B
380.5 B
380 B
379.5 B
379 B
378.5 B
378 B
377.5 B
377 B
376.5 B
376 B
375.5 B
375 B
374.5 B
374 B
373.5 B
373 B
372.5 B
372 B
371.5 B
371 B
370.5 B
370 B
369.5 B
369 B
368.5 B
368 B
367.5 B
367 B
366.5 B
366 B
365.5 B
365 B
364.5 B
364 B
363.5 B
363 B
362.5 B
362 B
361.5 B
361 B
360.5 B
360 B
359.5 B
359 B
358.5 B
358 B
357.5 B
357 B
356.5 B
356 B
355.5 B
355 B
354.5 B
354 B
353.5 B
353 B
352.5 B
352 B
351.5 B
351 B
350.5 B
350 B
349.5 B
349 B
348.5 B
348 B
347.5 B
347 B
346.5 B
346 B
345.5 B
345 B
344.5 B
344 B
343.5 B
343 B
342.5 B
342 B
341.5 B
 341 B
340.5 C
340 C
339.5 C
339 C
338.5 C
338 C
337.5 C
337 C
336.5 C
336 C
335.5 C
335 C
334.5 C
334 C
333.5 C
333 C
332.5 C
332 C
331.5 C
331 C
330.5 C
330 C
329.5 C
329 C
328.5 C
328 C
327.5 C
327 C
326.5 C
326 C
325.5 C
325 C
324.5 C
324 C
323.5 C
323 C
322.5 C
322 C
321.5 C
321 C
320.5 C
320 C
319.5 C
319 C
318.5 C
318 C
317.5 C
317 C
316.5 C
316 C
315.5 C
315 C
314.5 C
314 C
313.5 C
313 C
312.5 C
312 C
311.5 C
311 C
310.5 C
310 C
309.5 C
309 C
308.5 C
308 C
307.5 C
307 C
306.5 C
306 C
305.5 C
305 C
304.5 C
304 C
303.5 C
303 C
302.5 C
302 C
301.5 C
301 C
300.5 C
300 C
299.5 C
299 C
298.5 C
298 C
297.5 C
297 C
296.5 C
296 C
295.5 C
295 C
294.5 C
294 C
293.5 C
293 C
292.5 C
292 C
291.5 C
291 C
290.5 C
290 C
289.5 C
289 C
288.5 C
 288 C
287.5 C
287 C
286.5 C
286 C
285.5 C
285 C
284.5 C
284 C
283.5 C
283 C
282.5 C
282 C
281.5 C
281 C
280.5 C
280 C
279.5 C
279 C
278.5 C
278 C
277.5 C
277 C
276.5 C
276 C
275.5 C
275 C
274.5 C
274 C
273.5 C
273 C
272.5 C
272 C
271.5 C
271 C
270.5 C
270 C
269.5 C
269 C
268.5 C
268 C
267.5 C
267 C
266.5 C
266 C
265.5 C
265 C
264.5 C
264 C
263.5 C
263 C
262.5 C
262 C
261.5 C
261 C
260.5 D
260 D
259.5 D
259 D
258.5 D
258 D
257.5 D
257 D
256.5 D
256 D
255.5 D
255 D
254.5 D
254 D
253.5 D
253 D
252.5 D
252 D
251.5 D
251 D
250.5 D
250 D
249.5 D
249 D
248.5 D
248 D
247.5 D
247 D
246.5 D
246 D
245.5 D
245 D
244.5 D
244 D
243.5 D
243 D
242.5 D
242 D
241.5 D
241 D
240.5 D
240 D
239.5 D
239 D
238.5 D
238 D
237.5 D
237 D
236.5 D
236 D
235.5 D
 235 D
234.5 D
234 D
233.5 D
233 D
232.5 D
232 D
231.5 D
231 D
230.5 D
230 D
229.5 D
229 D
228.5 D
228 D
227.5 D
227 D
226.5 D
226 D
225.5 D
225 D
224.5 D
224 D
223.5 D
223 D
222.5 D
222 D
221.5 D
221 D
220.5 D
220 D
219.5 D
219 D
218.5 D
218 D
217.5 D
217 D
216.5 D
216 D
215.5 D
215 D
214.5 D
214 D
213.5 D
213 D
212.5 D
212 D
211.5 D
211 D
210.5 D
210 D
209.5 D
209 D
208.5 D
208 D
207.5 D
207 D
206.5 D
206 D
205.5 D
205 D
204.5 D
204 D
203.5 D
203 D
202.5 D
202 D
201.5 D
201 D
200.5 D
200 D
199.5 D
199 D
198.5 D
198 D
197.5 D
197 D
196.5 D
196 D
195.5 D
195 D
194.5 D
194 D
193.5 D
193 D
192.5 D
192 D
191.5 D
191 D
190.5 D
190 D
189.5 D
189 D
188.5 D
188 D
187.5 D
187 D
186.5 D
186 D
185.5 D
185 D
184.5 D
184 D
183.5 D
183 D
182.5 D
 182 D
181.5 D
181 D
180.5 D
180 D
179.5 D
179 D
178.5 D
178 D
177.5 D
177 D
176.5 D
176 D
175.5 D
175 D
174.5 D
174 D
173.5 D
173 D
172.5 D
172 D
171.5 D
171 D
170.5 D
170 D
169.5 D
169 D
168.5 D
168 D
167.5 D
167 D
166.5 D
166 D
165.5 D
165 D
164.5 D
164 D
163.5 D
163 D
162.5 D
162 D
161.5 D
161 D
160.5 D
160 D
159.5 D
159 D
158.5 D
158 D
157.5 D
157 D
156.5 D
156 D
155.5 D
155 D
154.5 D
154 D
153.5 D
153 D
152.5 D
152 D
151.5 D
151 D
150.5 D
150 D
149.5 D
149 D
148.5 D
148 D
147.5 D
147 D
146.5 D
146 D
145.5 D
145 D
144.5 D
144 D
143.5 D
143 D
142.5 D
142 D
141.5 D
141 D
140.5 D
140 D
139.5 D
139 D
138.5 D
138 D
137.5 D
137 D
136.5 D
136 D
135.5 D
135 D
134.5 D
134 D
133.5 D
133 D
132.5 D
132 D
131.5 D
131 D
130.5 D
130 D
129.5 D
 129 D
128.5 D
128 D
127.5 D
127 D
126.5 D
126 D
125.5 D
125 D
124.5 D
124 D
123.5 D
123 D
122.5 D
122 D
121.5 D
121 D
120.5 D
120 D
119.5 D
119 D
118.5 D
118 D
117.5 D
117 D
116.5 D
116 D
115.5 D
115 D
114.5 D
114 D
113.5 D
113 D
112.5 D
112 D
111.5 D
111 D
110.5 D
110 D
109.5 D
109 D
108.5 D
108 D
107.5 D
107 D
106.5 D
106 D
105.5 D
105 D
104.5 D
104 D
103.5 D
103 D
102.5 D
102 D
101.5 D
101 D
100.5 D
100 D
99.5 D
99 D
98.5 D
98 D
97.5 D
97 D
96.5 D
96 D
95.5 D
95 D
94.5 D
94 D
93.5 D
93 D
92.5 D
92 D
91.5 D
91 D
90.5 D
90 D
89.5 D
89 D
88.5 D
88 D
87.5 D
87 D
86.5 D
86 D
85.5 D
85 D
84.5 D
84 D
83.5 D
83 D
82.5 D
82 D
81.5 D
81 D
80.5 D
80 D
79.5 D
79 D
78.5 D
78 D
77.5 D
77 D
76.5 D
 76 D
75.5 D
75 D
74.5 D
74 D
73.5 D
73 D
72.5 D
72 D
71.5 D
71 D
70.5 D
70 D
69.5 D
69 D
68.5 D
68 D
67.5 D
67 D
66.5 D
66 D
65.5 D
65 D
64.5 D
64 D
63.5 D
63 D
62.5 D
62 D
61.5 D
61 D
60.5 D
60 D
59.5 D
59 D
58.5 D
58 D
57.5 D
57 D
56.5 D
56 D
55.5 D
55 D
54.5 D
54 D
53.5 D
53 D
52.5 D
52 D
51.5 D
51 D
50.5 D
50 D
49.5 D
49 D
48.5 D
48 D
47.5 D
47 D
46.5 D
46 D
45.5 D
45 D
44.5 D
44 D
43.5 D
43 D
42.5 D
42 D
41.5 D
41 D
40.5 D
40 D
39.5 D
39 D
38.5 D
38 D
37.5 D
37 D
36.5 D
36 D
35.5 D
35 D
34.5 D
34 D
33.5 D
33 D
32.5 D
32 D
31.5 D
31 D
30.5 D
30 D
29.5 D
29 D
28.5 D
28 D
27.5 D
27 D
26.5 D
26 D
25.5 D
25 D
24.5 D
24 D
23.5 D
 23 D
22.5 D
22 D
21.5 D
21 D
20.5 D
20 D
19.5 D
19 D
18.5 D
18 D
17.5 D
17 D
16.5 D
16 D
15.5 D
15 D
14.5 D
14 D
13.5 D
13 D
12.5 D
12 D
11.5 D
11 D
10.5 D
10 D
9.5 D
9D
8.5 D
8D
7.5 D
7D
6.5 D
6D
5.5 D
5D
4.5 D
4D
3.5 D
3D
2.5 D
2D
1.5 D
1D
0.5 D
0D