360° Feedback Form
Name VISHAL ANIL BHAMRE
Employee Code
669
Department PIPING
Objective:
Every organization has its own culture and values and a 360° survey emphasizes on just that. We have customized this
survey to reflect our core values by including questions about integrity, leadership, development and communication.
By means of this feedback form, we strive to achieve an overall sense of direction on the development of employees and
their communication of our leadership team.
Your feedback will help the organization in formulating the best strategy for a holistic growth of individuals, teams and
in a broader sense, the organization.
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Section 1.
Self-Feedback:
You have been asked to evaluate yourself as part of a 360-degree feedback process. Other employees, including your
manager(s), peers, direct reports and/or others will also evaluate you.
In this manner, you will be provided with a comprehensive, multi-perspective (i.e., 360-degree) view of your
performance. The objective is to provide you with feedback to allow you to improve your performance, resulting in
improved team performance, and organizational effectiveness.
1
Part 1- Accountability (Are you/ Do you)
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Act like an owner when you make
decisions.
2 Tackle issues head on and find
solutions.
3 Take responsibility for results
4 Take ownership of mistakes and
learns from them.
5 Inform the management of
progress without having to be
asked about it
Any Additional Comments?
Part 2- Communication Skills (Are you/ Do you)
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Accurately attend to/ understand
ideas which are exchanged.
2 An effective listener who is
responsive to information needs
3 Check for understanding
throughout conversations or
group presentations/discussions
2
4 Convey ideas confidently and
succinctly.
5 Deal with difficult situations
calmly and confidently
6 Deliver difficult messages to co-
workers in an appropriate manner
7 Have the confidence to
communicate effectively to all
levels (from CEO down) of the
organization, external customers,
suppliers, as well as the senior
counsel of other companies.
8 Listen actively & speaks clearly
and directly.
9 Visible and approachable
10 Present issues, ideas, and strategy
concisely and clearly.
Any Additional Comments?
Part 3- Situational Awareness (Are you/ Do you)
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Accept the views of others.
2 Actively seek feedback from
others.
3 Ask others for their ideas and
opinions.
4 Looks to others for input
3
5 Seeks and utilizes data from
several sources.
Any Additional Comments?
Part 4- Problem Solving (Are you/ Do you)
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Have the ability to solve problems
at root cause rather than at
symptom level
2 Able to develop innovative
solutions to problems
3 Collect relevant information and
data.
4 Make judgments based upon
relevant information.
5 Are aware of problems or issues
that may affect the organization?
Any Additional Comments?
4
Part 5- Teamwork (Are you/ Do you)
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Come across as a reliable,
committed team member
2 Contribute to and supports team
decision-making process
3 Create opportunities to learn with
other team members
4 Demonstrate compassion and
respect for others through actions;
are concerned about their work
and non-work issues
5 Facilitate team discussions and
problem-solving
6 Help other managers in need of
assistance, such as providing
needed resources (co-workers,
supplies, etc.)
7 Open to new ideas that may
change own goals for benefit of the
team
8 Open to the suggestions of others
when working on a problem?
9 Foster teamwork rather than
individual competition
10 Encourage Open Communication
Any Additional Comments?
5
Section 2.
Manager/ Direct Reporting Authority Feedback:
Name of Manager being Evaluated: Mr. Sashi Warrior (Please leave blank in case your reporting is directly to the Management/MD)
You have been nominated to provide feedback for the manager listed above. Your feedback is an important part of your
Manager’s leadership development process. This tool is intended to gather broad feedback in the core competencies and
role responsibilities that are important for the on-going success of our organization.
In responding to the assessment form, please think about your experiences working with this individual during your
tenure. Your responses will be merged with other's feedback and presented to the manager to guide them in their on-
going development.
Part 1- Accountability
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Acts like an owner when they
make decisions.
2 Can be counted on to do what
they say they are going to do.
3 Defines roles, rights, and
responsibilities of employees
4 Tackles issues head on and finds
solutions.
5 Takes responsibility for results.
6 Takes ownership of mistakes and
learns from them.
7 Is someone you can trust.
8 Is someone who is there when you
need them.
6
9 Encourages employees to take on
greater responsibilities
10 Informs supervisor of progress
without having to be asked about
it
Any Additional Comments?
Part 2- Communication Skills
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Accurately attends
to/understands ideas which are
exchanged.
2 An effective listener who is
responsive to information needs
3 Checks for understanding
throughout conversations or
group presentations/discussions
4 Communicates the vision of the
organization to all employees
5 Conducts regular performance
feedback discussions with
individuals and teams
6 Considers the audience in how the
communication is presented.
7 Conveys ideas confidently and
succinctly.
8 Conveys priorities with right sense
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of urgency and importance.
9 Informs others about changes or
developments in plans and goals
10 Deals with difficult situations
calmly and confidently
Any Additional Comments?
Part 3- Situational Awareness
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Accepts the views of others.
2 Asks others for their ideas and
opinions.
3 Seeks and utilizes data from
several sources.
4 Seeks feedback to enhance
performance.
5 Actively seeks feedback from
others.
Any Additional Comments?
Part 4- Leadership
S.N Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
8
Development Expected Average for Not
Others Aware
1 Maximizes the efforts of all team
members
2 Uses persuasion and influence
instead of micromanaging
employees
3 Able to influence others
4 Able to organize the work of others
5 Acts decisively in implementing
decisions
6 Holds co-workers accountable for
assignments and commitments
7 Critiques own performance as a
means of self-improvement and
initiates self-development
activities
8 Demonstrates empathy for the
impact of change on people and
processes
9 Encourages and is receptive to
working out problems and
challenges --- no reluctance from
team members to come forward
with concerns/issues.
10 Implements decision and
evaluates results.
Any Additional Comments?
9
Part 5- Problem Solving
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Ability to solve problems at root
cause rather than at symptom
level
2 Able to develop innovative
solutions to problems
3 Analyzes alternatives and selects a
course of action.
4 Assumes new and difficult
challenges and manages them as
opportunities.
5 Identifies fresh approaches and
shows a willingness to question
traditional assumptions.
6 Analyzes systems and processes
for opportunities to gain efficiency.
7 Selects operating indicators to
track organizational performance
over time and communicates
current status to the organization
8 Willingness and comfort level in
handling multiple and often times
conflicting priorities.
9 Is aware of problems or issues
that may affect the organization?
10 Looks for opportunities to
enhance contributions to the
bottom line?
Any Additional Comments?
10
Part 6- Teamwork
S.N Statement Needs Could Benefit Performs Excels; Is a Role Don’t
Improvement from as Above Model Know/
Development Expected Average for Not
Others Aware
1 Creates a culture that fosters and
values collaboration
2 Comes across as a reliable,
committed team member
3 Demonstrates compassion and
respect for others through actions;
is concerned about their work and
non-work issues
4 Ensures that the right people are
on the team in the appropriate
roles, including who should be
team leader for a particular
project/situation.
5 Facilitates conflict resolution
discussions between individuals
in different teams
Any Additional Comments?
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