Executive 360 Assessment
Copyright Brekke Consulting, Inc.
No part of this form may be reproduced without permission.
To inquire contact: davidbrekke(at)brekkeconsulting(dot)com


Your name: (your name is required but will not be shared)


Name of the person you are evaluating:

Name of this individual's company/organization:

Your individual responses will remain anonymous, only composite information will be shown to the feedback receiver and administering consultant.

What is your relationship to the individual you are evaluating?

Self: "I am evaluating myself."
Peer: "I am his or her collegue or manager."
Direct Report: "I am evaluating my manager."
Other: "The person I am evaluating is outside my department or does not fit into any of the above groups."

Instructions: How often does this person display the following behaviors? Select one circle corresponding to a number from "0" (never) to "10" (always). If you have not observed the behavior select the square next to "N/A" (not applicable). If you mark the questionnaire with all one number it will either be disregarded or you may be asked to submit the questionnaire again. As a rule of thumb use a particular score no more than 12 times. The goal is useful feedback, please consider your scoring carefully.

Takes an active interest in others.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Is friendly and approachable.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Listens and responds to other's ideas.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Searches for common ground to resolve conflict.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Respects other's feelings and attitudes.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Accepts criticism graciously and seriously.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Shares the credit for team accomplishments with the team.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Participates in team discussions.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Attempts to build consensus around team goals.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Shares or personally accepts blame for team failures.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Solicits feedback from others on important topics.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Makes an effort to support team decisions.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Makes sure everyone has the information to do his or her job.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Shares relevant information in a timely manner.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Communicates in a clear forthright manner.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Provides honest and reliable information.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Communicates the priority and purpose of assigned tasks.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Job expectations are clearly communicated.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Offers advice in a helpful, non-threatening way.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Motivates others by example.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Freely offers praise for good work.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Answers questions thoroughly and patiently.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Assists others in achieving career goals.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Is available when assistance or guidance is most needed.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Works to identify the underlying causes of problems.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Presents a long-term view of opportunities and challenges.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Pursues new strategies to overcome stubborn obstacles.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Gathers relevant information before making a decision.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Offers multiple perspectives from which to view an issue.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Encourages appropriate risk taking.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Takes steps to initiate positive change.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Completes tasks in a timely manner.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Accepts responsibility for mistakes.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 

Produces high quality results.

Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Appropriately delegates responsibility.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 
Maintains a high degree of personal integrity in business relationships.
Never 
0
1
2
3
4
5
6
7
8
9
10
Always
   N/A   
 


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Please provide additional comments in the space provided.

Additional Comments:

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Brekke Consulting Inc. retains the right to summarize comments as needed.

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