MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION EMPLOYEE APPLICATON FOR PROMOTION TO CHILDREN’S SERVICE WORKER III
Section 1: To be Completed by Employee
Employee Name:	Last Four of SSN:
Program Area:	Date Employee Became Children’s Service Worker II:
In what ways have you demonstrated that you are prepared to serve as a Children’s Service Worker III? What are your most significant strengths (e.g. knowledge, skills, behavior, and attitude)? In what areas do you need further development?
Employee’s Signature:	Date:
Section 2: To be completed by Supervisor
Supervisor Name:
Has Applicant been a Children’s Service Worker II for 2 years? Yes No	Level of Supervision this employee requires (e.g. minimal, routine, intensive)	What was the Employee’s last PERforM rating (include score).
Do you agree with the employee’s comments above? Yes No If no, please explain:
What additional strengths or developmental areas have you observed?
Has the employee received any discipline or been on a corrective action plan in the last 12 months? Yes No If yes please explain:	Does this employee understand and implement policy and practice in a way that reflects a strategic thinking, deliberate interventions, evaluation, and multi-tasking? Yes No If No, please explain:
Is the employee self-motivated and have the ability to model best practices for others? Yes No If no, please explain:	Does this employee have ability to utilize knowledge and experience to make informed decisions with less supervisory input? Yes No If no, please explain:
Does this employee have the ability to perform work that requires a high level of technical expertise in several areas within their total job duties? Yes No If no, please explain:	Does this employee have refined communication skills and the ability to produce written products and consistent and thorough documentation? Yes No If no, please explain:
Why do you feel this employee is prepared to serve as a Children’s Service Worker III? Include based observations on their performance and competencies? (“Missouri Children’s Division - Children’s Service Worker Competencies” available as resource material)
Supervisor’s Signature:	Date:
Section 3: To be completed by Program Manager (if applicable) and Circuit Manager
Program Manager Name (if applicable):
Has this employee met all the requirements and are they prepared for promotion to the Children’s Service Worker III classification? Yes No If no, please explain:
Any additional Comments:
Program Manager Signature:	Date:
Circuit Manager Signature:	Date:
Section 4: To be completed by Field Support Manager (if applicable) and Regional Director
Field Support Manager Name:
Has this employee met all the requirements and are they prepared for promotion to the Children’s Service Worker III classification? Yes No If no, please explain:
Any additional Comments:
Field Support Manager Signature:	Date:
Regional Director Signature:	Date:
Section 5: To be completed by Human Resources Manager
Did employee have any discipline in the last 12 months?	What was the Employee’s last PERforM rating (including score):
Promote to Children’s Service Worker III? Yes No If yes, effective date of promotion:
Human Resource Manager Signature:	Date: