Role Model Assessment Form
Evaluate and provide feedback on an individual's qualities and effectiveness as a role model.
Assessed Person's Full Name
*
First Name
Last Name
Your Full Name
*
First Name
Last Name
Your Relationship to the Assessed Person
*
Please Select
Peer
Supervisor/Manager
Mentor
Student/Mentee
Other
Rate the following qualities of the assessed person:
*
Rows
Integrity
Leadership
Communication Skills
Empathy
Responsibility
Inspiration
Excellent
1
2
3
4
5
6
Good
7
8
9
10
11
12
Average
13
14
15
16
17
18
Needs Improvement
19
20
21
22
23
24
How strongly do you agree with the following statement: 'This person sets a positive example for others.'
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
How likely are you to recommend this person as a role model to others?
*
1
2
3
4
5
What specific actions or behaviors make this person a good role model?
*
In what areas could this person improve to become a better role model?
Provide any additional comments or examples that support your assessment.
Signature (Please sign to confirm your assessment)
*
Submit Assessment
Submit Assessment
Should be Empty: