Coaching for Excellence - Board of Directors CEO Assessment Form

1. Company Name Here
FY Enter Year Here Board Assessment
The following survey is intended to assist the Board of Directors of Company Name Here, Inc.
(“Company Name Here”) in evaluating the effectiveness of the Board. You are encouraged to
be objective and candid in responding to this survey.
The Nominating Committee will be responsible for coordinating the evaluation, reviewing the
summary results of the survey and providing a report to the Board at the regular quarterly
meeting scheduled for Date Here. The report will not attribute specific ratings or comments to
individual directors. After the evaluation has been completed, the survey documents will be
destroyed pursuant to Company Name Here document retention guidelines. The General
Counsel will assist the Nominating Committee in compiling the results of the board evaluation
process.
For each of the categories below, please indicate to what extent you agree with the statements.
You may provide additional comments in the space provided below each statement or on the
separate sheet attached to this document.
Once you have completed the survey, please return it to Name of Internal Employee Here
pursuant to the instructions at the end of this document. You should complete and return the
survey by Date Here.
Circle one response for each item (1, 2, 3, 4 or 5)
With regard to the following areas that are primarily
the responsibility of the Chairman, the Board of
Directors....................................................................
Strongly
Disagree Disagree
Neither
Agree
Disagree Agree
Strongly
Agree
1. Has meetings that encourage open communication
(in which members actively and objectively
participate in discussions) and result in timely
resolution of issues.
1 2 3 4 5
Comments:
2. Has and follows procedures for effective meetings. 1 2 3 4 5
Comments:
3. Has a committee structure that balances work and
responsibilities appropriately between committee
and full board meetings.
1 2 3 4 5
Comments:
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2. Circle one response for each item (1, 2, 3, 4 or 5)
With regard to the following areas that are primarily
the responsibility of the CEO and senior
management, the Board of Directors......................
Strongly
Disagree Disagree
Neither
Agree
Disagree Agree
Strongly
Agree
4. Receives appropriate materials - i.e., accurate
minutes, advanced written agendas and meeting
notices and clean and concise background
materials - sufficiently in advance of meetings to
permit effective participation.
1 2 3 4 5
Comments:
5. Receives presentations from management that are
focused and informative. 1 2 3 4 5
Comments:
6. Receives sufficient information relating to Company
Name Here industry to monitor Company Name
Here performance relative to its peers.
1 2 3 4 5
Comments:
7. Receives sufficient information regarding trends
and issues affecting Company Name Here
business and industry.
1 2 3 4 5
Comments:
8. Has sufficient exposure to management and input
into senior management succession plans.
1 2 3 4 5
Comments:
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3. 9. Monitors annual capital and operating budgets,
cash flow, profitability, revenue, expenses and
other financially driven indicators.
1 2 3 4 5
Comments:
Circle one response for each item (1, 2, 3, 4 or 5)
With regard to the following areas that are primarily
the responsibility of the Board, the Board of
Directors....................................................................
Strongly
Disagree Disagree
Neither
Agree
Disagree Agree
Strongly
Agree
10. Reviews the Company Name Here corporate
strategy on a regular basis and effectively monitors
the implementation of this strategy.
1 2 3 4 5
Comments:
11. Reviews and understands Company Name Here
annual business plan, monitors progress against
this plan, and inquires into significant performance
deficiencies.
1 2 3 4 5
Comments:
12. Focuses on activities that help Company Name
Here maximize long-term performance and
shareholder value.
1 2 3 4 5
Comments:
13. Communicates its goals, expectations and
concerns to the CEO and senior management.
1 2 3 4 5
Comments:
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4. 14. Respects the difference between the Board's policy
making and oversight role and the role of the CEO
and senior management to manage Company
Name Here business.
1 2 3 4 5
Comments:
15. Ensures (through the Audit Committee and
Nominating Committee) that reasonable policies
and procedures are in place to promote ethical
behavior and legal compliance throughout the
organization.
1 2 3 4 5
Comments:
16. Evaluates and approves performance-based
compensation plans for management and regularly
evaluates management’s performance.
1 2 3 4 5
Comments:
17. Has sufficient information and effective processes
to assess the performance of the CEO.
1 2 3 4 5
Comments:
18. Orients and integrates new directors effectively,
and assures procedures are in place to educate
new directors and provide continuing education for
directors.
1 2 3 4 5
Comments:
19. Has an appropriate number of meetings each year. 1 2 3 4 5
Comments:
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5. 20. Has effective sessions of independent and non-
employee directors.
1 2 3 4 5
Comments:
Circle one response for each item (1, 2, 3, 4 or 5)
With regard to the following areas that are primarily
the responsibility of the Directors acting
individually, the Directors........................................
Strongly
Disagree Disagree
Neither
Agree
Disagree Agree
Strongly
Agree
21. Spend sufficient time with materials provided by
management and are prepared for meetings.
1 2 3 4 5
Comments:
22. Understand Company Name Here values, business
plan, strategic plan and long range strategic
direction.
1 2 3 4 5
Comments:
23. Stay abreast of issues and trends affecting
Company Name Here and its industry, and use this
information to oversee Company Name Here
performance and strategic direction.
1 2 3 4 5
Comments:
24. Are active participants in Board and Committee
meetings.
1 2 3 4 5
Comments:
25. Have open lines of communication to the CEO,
senior management and other directors.
1 2 3 4 5
Comments:
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6. Circle one response for each item (1, 2, 3, 4 or 5)
With regard to the structure of the Board and
Committees, the Board…………………………………
Strongly
Disagree Disagree
Neither
Agree
Disagree Agree
Strongly
Agree
26. Has an appropriate number of directors. 1 2 3 4 5
Comments:
27. Has an appropriate number of independent
directors.
1 2 3 4 5
Comments:
28. Is comprised of directors with an appropriate level
of skill, experience, knowledge and diversity.
1 2 3 4 5
Comments:
29. Has an appropriate process for identifying,
reviewing and nominating directors.
1 2 3 4 5
Comments:
30. Has an appropriate committee structure. 1 2 3 4 5
Comments:
Additional comments may be provided on the attached sheet.
You may complete either a hardcopy or electronic version of this survey. Your response should be
sent to Ed Internal Employee / General Counsel Name Here, at the address set forth below via e-mail
or US mail.
COMPANY NAME HERE
Address Here
City, State, Zip Code Here
Attn: Internal Employee / General Counsel Name Here
e-mail: Email Address Here
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7. Additional Comments
CONFIDENTIAL 7