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Run: AmeriCorps Member End-of-Term Evaluation and Exit

An AmeriCorps member end-of-term evaluation and exit form for confirming hours served, documenting performance, and recording the exit reason tied to educati...

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Program and Submission Context

AmeriCorps Program Name (required)

CNCS Grant Number (required)

Found on your Notice of Grant Award (NGA). Required for National Service Trust notification.

Program Year (required)

Date of This Evaluation (required)

Program Director / Authorized Staff Completing This Form (required)

Title (required)

Program Director Email (required)

Program Director Phone

Member Identification

Member Full Name (Legal Name) (required)

Member Email Address (required)

Used to match the member record in My AmeriCorps.

My AmeriCorps Member ID (if known)

Optional — helps staff locate the member record in the My AmeriCorps portal.

Service Position Title (required)

Service Slot Type (required)

Select the slot type as defined in your approved grant application.

If 'Other', specify slot type and required hours

Term Start Date (required)

Term End Date (Scheduled or Actual) (required)

Hours Served

Required Hours for This Slot Type (required)

Enter the minimum hours required for the selected slot (e.g., 1700 for full-time).

Total Verified Service Hours Completed (required)

Total hours as recorded in the program's approved timekeeping system. Do not include training hours unless your grant specifically allows them.

Total Training Hours (if tracked separately)

Optional. Enter only if your program tracks training hours separately from service hours.

Timekeeping System Used to Verify Hours (required)

Specify Timekeeping System

Hours Verified By (Name and Title) (required)

Notes on Hours (e.g., approved leave, medical absence, make-up hours)

Document any approved absences, leave without pay, or other circumstances affecting the total. Reference your program's approved leave policy.

Exit Determination

Exit Type (required)

Select the exit type that best describes this member's end of service.

Primary Reason for Exit (required)

Select the category that best describes why the member is exiting.

Describe the Circumstances of Exit (required)

Provide a factual, objective narrative. For cause exits, reference the specific policy or agreement provision violated. For compelling circumstances, document the nature of the hardship without including unnecessary medical or personal detail.

Education Award Recommendation (required)

Based on hours served and exit type, what is the program's recommendation for the National Service Trust?

Justification for Partial Award (if applicable)

If recommending a partial award, document the compelling personal circumstances or program-convenience basis per 45 CFR § 2522.230.

For Cause Exit — Supporting Documentation Attached?

Attach or reference written warnings, investigation summaries, or other documentation supporting the for-cause determination.

Upload Supporting Documentation (For Cause Exit)

Upload written warnings, performance improvement plans, or investigation summaries. Redact third-party PII before uploading.

Performance Evaluation

Reliability and Attendance (required)

Consistency in reporting to service site on time and as scheduled.

Quality of Service Delivered (required)

Effectiveness and impact of the member's direct service activities.

Teamwork and Collaboration (required)

Ability to work constructively with staff, fellow members, and community partners.

Professionalism and Conduct (required)

Adherence to member agreement, code of conduct, and program policies.

Initiative and Professional Growth (required)

Willingness to take on challenges, seek feedback, and develop skills during the term.

Overall Performance Rating (required)

Holistic assessment of the member's service term.

Performance Narrative (required)

Provide a brief, objective summary of the member's key accomplishments, areas of growth, and any performance concerns. This narrative may be shared with the member.

Notable Strengths

Optional. Highlight specific skills, contributions, or qualities that stood out.

Areas for Development

Optional. Note skills or behaviors the member should continue developing in future roles.

Training and Development Completion

Required Trainings Completed (required)

Select all required trainings the member completed during the term.

Required Trainings NOT Completed (if any)

List any required trainings the member did not complete and explain why.

Additional Certifications or Credentials Earned During Term

Member Acknowledgment

Did the member review this evaluation? (required)

Member Review Notes / Reason Not Reviewed

If the member disagreed, was unavailable, or refused, document the circumstances here.

Member's Written Comments (if any)

If the member provided written comments or a rebuttal, summarize or attach them here.

Member Signature

Member signature acknowledges receipt of this evaluation. It does not necessarily indicate agreement with the content.

Member Signature Date

Copy of Evaluation Provided to Member? (required)

Program Director Certification

Has the member's exit been entered in My AmeriCorps (the CNCS portal)? (required)

Exit must be recorded in My AmeriCorps within 30 days of the exit date to avoid Trust notification delays.

Date Exit Entered in My AmeriCorps

Program Director Certification

By signing below, I certify that: (1) the information in this evaluation is accurate and complete to the best of my knowledge; (2) the hours reported were performed in accordance with the approved grant and member service agreement; (3) the exit determination is consistent with program policy and CNCS requirements under 45 CFR Part 2522; and (4) I understand that false certification may result in grant sanctions and repayment obligations.

Program Director Signature (required)

Signature Date (required)

Secondary Reviewer Name and Title (if required by program policy)

Some programs require a second authorized staff member to co-sign end-of-term evaluations. Leave blank if not applicable.

Secondary Reviewer Signature

Attach Supporting Documents (optional)

Attach timesheet summaries, training certificates, or other documentation supporting this evaluation. Redact unnecessary PII before uploading.

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