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
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.
Makes an effort to support team decisions.
Makes sure everyone has the information
to do his or her job.
Communicates in a clear forthright manner.
Provides honest and reliable information.
Offers advice in a helpful, non-threatening
Motivates others by example.
Freely offers praise for good work.
Answers questions thoroughly and patiently.
Assists others in achieving career goals.
Is available when assistance or guidance
is most needed.
Presents a long-term view of opportunities
Pursues new strategies to overcome stubborn
Completes tasks in a timely manner.
Accepts responsibility for mistakes.
Produces high quality results.
Your comments about this individual are an important part
of this assessment.
Please provide additional comments in the space provided.
Your comments will be organized by topic and
any personal identifiers removed.
Brekke Consulting Inc. retains the right to summarize
comments as needed.
the button below when you have completed filling out the form.
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