FORM–A

PART–I
(To be filled by the Officer reported upon)

01. A Brief Summary of duties and responsibilities (Not more than 50 Words)

02. Please specify important items of work in order of priority where in

quantitative / Physical / Financial Targets / Objectives / Goals were set for
you or set by yourself for the reporting year and achievements made:

S. Physical or Financial
Item of Work Achievements
No. Target / Objectives / Goal
01 02 03 04
01
02
03
04
05

03. a.) In Case of short fail of expected Quality / Quantity of

performance, Please state the reasons.

b.) Please, indicate your contribution, in case of significantly Higher

achievements of the Target / Goal / Objective.
 FORM–A
P A R T – II

ANNUAL CONFIDENTIAL REPORT OF NON GAZETTED OFFICER

POSTS WHICH ARE FEEDER CATEGORIES TO INITIAL GAZETTED
POSTS IN STATE SERVICES FOR THE YEAR 2017 – 2018

01. Name

02. Post Held

Date of
a.) Birth
b.) Entry into Government Service
03. c.) Present Grade and Pay

Knowledge of
a.) Branch or Section
04. b.) Department

Acceptance or otherwise of the Self

appraisal report of the Non-Gazetted
05.
Officers indicated in Part – I and if not
agreed to the reasons therefore.
06. Personality, conduct and character
07. Power of taking responsibility
08. Initiative
a.) Judgement
09.
b.) Accuracy
10. Tact and Temper
11. Power of Supervising Staff
12. Zeal and Industry
13. Health
14. Attendance
15. Capacity to Note and Drafts
Punishment, Censures or special
16. commendations during the period under
report
Date of Communication of adverse remarks,
17.
if any to the Officer since last report
18. Indebtedness (indicated, the extent of
personal responsibility of incurring the
debts)
 a.) Date of Submission of Annual Property
returns Statement pertaining to the Year
2017.
Is he/she confirmed in this Post? If not, what
19.
is his/her Substantive Post?
General Remarks (including a Statement on
Discipline, Integrity, Reliability and any
20.
other special qualifications not included
above)
Grading
a.) Out standing
b.) Very Good
c.) Good
21. d.) Satisfactory
e.) Poor
(Clearly indicate the reasons for grading of
the Officers)
22. Reporting Officer

Signature
Name and
Designation
Date: (IN BLOCK
LETTERS)

23. Remarks of the Countersigning Officer

Signature
Date: Name and
Designation

Opinion of the Head of the Department on

24. the conduct and efficiency of the Officer
reported on

Signature
Name (IN BLOCK LETTER)
Date: Head of the
Department