Confidential

Feedback Form

·         PC: _____________________________

·         PBC:____________________________

·         Observer:_________________________

·         Domains of Effectiveness:  Partial List

§         3 Core Competencies: Connection, Clarification, Commitment

§         CIM Process: Openings, Possibilities, Plans, Outcomes. Action

§         Coaching Abilities: Listening, Observing, Discernment, Modeling, Delivery

§         Delivery:  feedback, questions, statements, challenges, ideas

§         Learning:  Performance, Change, Transformation

§         Ready/Willing/Able

§         Espoused Theory/Theory in Use

§         Perspective Taking

·         Overall Impression:

 Suggestions for improvement:

Reported by:  _____________________________________