Form NRC Form 212 NRC Form 212 Qualifications Investigation Professional, Technical, an

NRC FORM 212
(MM-YYYY)
NRC MD 10.1

U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0033

QUALIFICATIONS INVESTIGATION
PROFESSIONAL, TECHNICAL, AND
ADMINISTRATIVE POSITIONS

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 minutes. This
information is used to determine the qualifications and suitability of external applicants for
employment. Send comments regarding burden estimate to the FOIA, Privacy, and Information
Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001,
or by internet e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of
Information and Regulatory Affairs, NEOB-10202, (3150-0033), Office of Management and Budget,
Washington, DC 20503. If a means used to impose an information collection does not display a
currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not
required to respond to, the information collection.

The applicant named below has applied for a position in the NRC. Please rate the applicant in the items listed below with
respect to the period of time you either supervised or were acquainted with the applicant. Include any comments you may
feel are relevant. Please return the completed form to the Human Resources Specialist listed in the "FROM" block by the
return date indicated, sealed in the enclosed envelope and marked For Addressee Only.
Name of applicant
Position for which applied
TO: (Name & title of supervisor or reference)

Applicant's position with your company

FROM:

Human Resources Specialist
Office of the Chief Human Capital Officer
U. S. Nuclear Regulatory Commission
Washington, DC 20555
Confirmed Dates of Employment

End Date

Start Date

TECHNICAL AREA:
How well did the applicant know the work?

Above Average

Average

Below Average

How well did the applicant perform?

Above Average

Average

Below Average

How well did the applicant manage the workload?

Above Average

Average

Below Average

What were his/her strengths?

What were his/her weaknesses?

NRC FORM 212 (MM-YYYY)

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NRC FORM 212
(MM-YYYY)
NRC MD 10.1

U. S. NUCLEAR REGULATORY COMMISSION

QUALIFICATIONS INVESTIGATION PROFESSIONAL,
TECHNICAL, AND ADMINISTRATIVE POSITIONS (continued)

CHARACTERISTICS:
Was the applicant dependable?

Above Average

Average

Below Average

How did the applicant work in stressful situations?

Above Average

Average

Below Average

How would you describe the applicant's relationship with:
Co-worker

Supervisors

Higher Level Officials

REQUIRED QUESTIONS:
1. Have you any reason to question this applicant's trustworthiness or loyalty to the U. S.?
Yes

No

2. Do you know of any personal habits or characteristics that would make this applicant unsuitable for employment by the U. S. Government?
Yes

No

Yes

3. Is this applicant eligible for re-hire in your organization?

Relationship to Applicant:

Supervisor

Co-worker

Professional

No

Other (Specify)

NOTE: Consistent with the Privacy Act of 1974, this evaluation may be revealed to the applicant upon his or her
request. However, if you request, your identity and other identifying information will be kept confidential.
My Identity May be Revealed

I Request My Identity be Kept Confidential

Typed Name and/or Title of Interviewer

Signature of Interviewer

Date

Additional Comments

NRC FORM 212 (MM-YYYY)

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