DA Annual Review — Smile Haus

Part I — KPIs

0/40

Part II — Performance

0/75

Total Score

0/115

Fill in scores below

—

Select tier & enter scores

Employee Information

DA Name

Home Office

Current Hourly Rate ($)

Current Tier

Review Period

Review Date

Reviewer (OM Name)

Hire Date

Rating Scale · 1 Does Not Meet · 2 Partially Meets · 3 Meets Expectations · 4 Exceeds · 5 Outstanding

Part I — KPI Performance

/ 40 pts

KPI	Target	Score (1–5)

Part I Total: 0 / 40

KPI Notes — Data Sources, Context, Exceptions

Part II — In-Office Performance

/ 75 pts (15 criteria × 5)

Review Narrative

Strengths

Growth Areas

Goals for Next 12 Months

Employee Response / Comments

Tier Competency Checklist

Gate A · Gate B

Mark each skill: ✓ Can do or ✗ Cannot do. Leave blank if not yet evaluated. Gate A = all skills at current tier and below are ✓. Gate B = all skills at next tier are also ✓ (required to promote).

Gate A — Current Tier Mastery

Select your tier above

Required for any raise

Gate B — Next Tier Mastery

Select your tier above

Required for promotion + score ≥ 85

Signatures & Submission

Employee

Employee Signature (typed name)

Date

Office Manager

OM Signature (typed name)

Date

Submitting emails a raise summary to leadership and creates a ClickUp approval task. Configure both via Settings (gear icon, top right).

Employee Information

Part I — KPI Performance

Part II — In-Office Performance

Review Narrative

Tier Competency Checklist

Signatures & Submission

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