Part I.
Individual Performance Commitment and Accountability
(Professional/Technical)
I, Mary Jean S. Dispo, Midwife III, Quezon City Health Deparment commit and assume
accountability and full management support to deliver the Division's work outputs and agree to be rated
accordingly against performance measures set for the period 2nd semester of 2024.
January 6, 2025
Signature of Employee Date
Performance Criteria
(D) Average Point Weighted
Weigth Score (H)
Outputs Duration of Completion Quantity Quality Timeliness Point Score
Value (ExAWS) +
(A) (B) 10% 50% 40% (FxAWS) + (I)
(C)
(E) (F) (G) (GxAWS)/ 3 (C x H)
Provide Complete Quality
JULY - DECEMBER 2024 35% 0.00 0.00 0.00 0.00 0.00
Prenatal Care
Provide Complete Quality
JULY - DECEMBER 2024 35% 0.00 0.00 0.00 0.00 0.00
Postpartum Care
Review, analyze and
submit records and JULY - DECEMBER 2024 30% 0.00 0.00 0.00 0.00 0.00
reports
Total Weighted Value 100%
Average Point Score/ Total Weighted Point Score 0.00
Part I - Equivalent Point Score (75%) 0.00 0.75 0.00
Part II - Total Point Score (25%) 4.00 0.25 1.00
Part III = Total Equivalent Point Score (Part I + Part II) 1.00
Equivalent Numerical Rating
Adjectival Rating VERY SATISFACTORY
Approved by:
KAREN GEMMA A. SEE, MD
MEDICAL OFFICER IV
DISTRICT II HEALTH OFFICE
QCG.HRMD.HRPODD.F.01
QUEZON CITY GOVERNMENT
QUEZON CITY HEALTH DEPARTMENT
July to December 2024
WORK OUTPUT MONITORING FORM FOR INDIVIDUAL
Name: Mary Jean S. Dispo ( ) Managerial /Supervisory
Position: Midwife III (√ ) Professional/Technical
Officer/ Employee No. 0028924 Contact No. ( ) Administrative/Clerical
Work Output: PROVIDE COMPLETE QUALITY PRENATAL CARE
Performance Total
Measurement Method July Aug Sept Oct Nov Dec
Criteria Score
(5) 0 -1 valid complaint; every aspect
or detail of work assignment is
complied with; well organized in the
delivery of service; work in
accordance with instructions;
(4) With 2 - 3 valid complaints in the
delivery of service; minimal
supervision needed; work in
accordance with instructions
Quality 0
(3)Wiith 4 - 5 valid complaints in the
delivery of service; close monitoring &
supervision needed;
(2)Wiith more than 5 valid complaints
in the delivery of service;
constant monitoring supervision is
needed; mentoring / coaching is vital
(5) 9% or more of the Completed AP
Care per month
(4) 8% of the Completed AP Care per
month
Quantity d (3) 7 - 7.9% of the Completed AP Care 0
per month
(2) Less than 7% of the Completed AP
Care per month
(5) 8% or more of the Completed AP
Care has been accomplished 4 days or
more before the last working day of the
month
(4) 8% or more of the Completed AP
Care has been accomplished 1- 3 days
Timeliness
before the last working day of the
month
(3) 8% of the Completed AP Care has
been accomplished on the last working
day
(2) Less than 8% of the Completed AP
Care has been accomplished on the last
working day
Total Score/ Average Weighted Score:
Agreed on Target Rating Conforme:
Rater
CHARISE LEAH A. NEBRIDA, MD
Ratee
MARY JEAN S. DISPO, RM
QCG.HRMD.HRPODD.F.02
QUEZON CITY GOVERNMENT
QUEZON CITY HEALTH DEPARTMENT
July to December 2024
WORK OUTPUT MONITORING FORM FOR INDIVIDUAL
Name: Mary Jean S. Dispo ( ) Managerial /Supervisory
Position: Midwife III (√ ) Professional/Technical
Officer/ Employee No. 0028924 Contact No. ( ) Administrative/Clerical
Work Output: PROVIDE COMPLETE QUALITY POSTPARTUM CARE
Performance Total
Measurement Method July Aug Sept Oct Nov Dec
Criteria Score
(5) 0 -1 valid complaint; every aspect
or detail of work assignment is
complied with; well organized in the
delivery of service; work in
accordance with instructions;
(4) With 2 - 3 valid complaints in the
delivery of service; minimal
supervision needed; work in
Quality accordance with instructions 0
(3)Wiith 4 - 5 valid complaints in the
delivery of service; close monitoring &
supervision needed;
(2)Wiith more than 5 valid complaints
in the delivery of service;
constant monitoring supervision is
needed; mentoring / coaching is vital
(5) 9% or more of the Completed PP
Care per month
(4) 8% of the Completed PP Care per
month
Quantity (3) 7 - 7.9% of the Completed PP Care 0
per month
(2) Less than 7% of the Completed PP
Care per month
(5) 8% or more of the Completed PP
Care has been accomplished 4 days or
more before the last working day of the
month
(4) 8% or more of the Completed PP
Care has been accomplished 1- 3 days
Timeliness
before the last working day of the
0
month
(3) 8% of the Completed PP Care has
been accomplished on the last working
day
(2) Less than 8% of the Completed PP
Care has been accomplished on the last
working day
Total Score/ Average Weighted Score:
Agreed on Target Rating Conforme:
Rater
CHARISE LEAH A. NEBRIDA, MD
Rater
CHARISE LEAH A. NEBRIDA, MD
Ratee
MARY JEAN S. DISPO, RM
QCG.HRMD.HRPODD.F.02
QUEZON CITY GOVERNMENT
QUEZON CITY HEALTH DEPARTMENT
July to December 2024
WORK OUTPUT MONITORING FORM FOR INDIVIDUAL
Name: Mary Jean S. Dispo ( ) Managerial /Supervisory
Position: Midwife III (√ ) Professional/Technical
Officer/ Employee No. 0028924 Contact No. ( ) Administrative/Clerical
Work Output: REVIEW, ANALYZE AND SUBMIT RECORDS AND REPORTS
Performance Total
Measurement Method July Aug Sept Oct Nov Dec
Criteria Score
(5) NO mistakes or deficiencies; well
presented and organized
(4) 1 revision with 2 - 3 minor errors or
deficiencies in the submitted report
Quality 0 0 0 0 0 0 0
(3) 1 revision with 4 - 5 minor errors or
deficiencies in the submitted report
(2) 2 or more revisions of the submitted
report
(5) 6 reports submitted per month
(FHSIS, M1, TT per bgy, MORE,
Adolescent Tracking, FeSO4 tab
inventory) to District Office
Quantity (4) 5 reports submitted per month 0 0 0 0 0 0 0
(3) 4 reports submitted per month
(2) 3 reports submitted
(5) Submitted all needed reports to the
District Office on the 1st working day
of the following month
(4) Submitted all needed reports to the
District Office on the 2nd working day
Timeliness
of the following month
0 0 0 0 0 0 0
(3) Submitted all needed reports to the
District Office on the 3rd working day
of the following month
(2) Submitted all needed reports to the
District Office after the 3rd working
day of the following month
Total Score/ Average Weighted Score:
Agreed on Target Rating Conforme:
Rater
CHARISE LEAH A. NEBRIDA, MD
Ratee
MARY JEAN S. DISPO,RM
QCG.HRMD.HRPODD.F.02
al /Supervisory
nal/Technical
rative/Clerical
Average
Weighted
Score
#DIV/0!
#DIV/0!
#DIV/0!
0.00
D.HRPODD.F.02
al /Supervisory
nal/Technical
rative/Clerical
Average
Weighted
Score
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
D.HRPODD.F.02
al /Supervisory
nal/Technical
rative/Clerical
Average
Weighted
Score
0.00
0.00
0.00
0.00
D.HRPODD.F.02
Part II. Professional/Technical Attributes and Practices affecting Job
Behavior and Work Performance
Covers activities, measures attitudes and behavior towards policy complaiance and in the identification, prioritization and allocation of resources as
essential components in performing and accomplishing individual commitments.
Unsatisfactory
Justifications
Outstanding
Satisfactory
Satisfactory
Very
With
Competencies
2 3 4 5
1. Polite, gracious, kind and thoughtful dealings and behavior towards customers in
terms of speech and actions. Customer needs are listened to and addressed with
immediate/workable solutions even beyond scope of responsibility.
2. Respects others' views and concerns, and abides by office norms, policies and
agreements; offers and seeks assistance when applicable to achieve results set.
3. Takes on different roles as need arise; helps address interpersonal issues and
concerns
4. Observes high standards of work and ethical behavior pursuant to RA 6713;
Assumes responsibility and accountability for his actions, guided by his approved
individual commitment; supports what is truthful and honest undertakings.
5. Punctual at work, appointments, meetings, reports submission and available
when needed; follows mandated dress code; attends flag ceremony and other
organizational activities.
6. Performs assigned tasks according to guidelines set, without internal/external
pressures and under minimal supervision.
7. Adapts to new situations objectively, has self-control and appropriateness of
behavior to situations.
8. Continues working toward a goal despite oppositions or difficulties even though
success appears to be far into the future.
9. Has ability to learn new ways and details in relation to work.
10. Allocates available resources to competing demands by setting task priorities
based on service delivery with due regard to office rules/regulation.
11. Addresses likely contingencies within his level; remains flexible.
12. Sets the example by displaying high standards of duty performance, personal
appearance, professional bearing, and ethics.
13. Remains positive when the situation becomes confused or changes. Supports
equal opportunity.
14. Participates in team tasks and issions without being requested to do so.
Suggests ways to improve service delivery.
Total Score
Average point score (Total Score divided by 14)
RATEE: __________________________________
RATER: __________________________________
QCG.HRMD.HRPODD.F.02
affecting Job
ocation of resources as
Total Points
Score
G.HRMD.HRPODD.F.02
