Name:_____________________
Dates covered: ___/___/ ___ to ___/___/ ___
1. Three improvements in my work this week were
1.
2.
3.
2. The one behavior which I have targeted for improvement is...
3. My action plan for changing this behavior during the coming week is...
4. My supervisor's assessments of my work this week indicated that he/she thinks...
5. The most important thing I learned this week was...