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

U.S. NUCLEAR REGULATORY COMMISSION

APPROVED BY OMB: NO. 3150-0033

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory collection request: 15 minutes.
This information is used to determine the qualifications and suitability of external applicants for
employment. Send comments regarding burden estimate to the Records and FOIA/Privacy
Services Branch (T-5 F52), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001,
or by internet e-mail to [email protected], 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.
DATE

RETURN BY (Date)

POSITION FOR WHICH APPLIED

TO: NAME OF SUPERVISOR / REFERENCE

FROM:

TITLE OF APPLICANT'S POSITION WITH YOUR COMPANY

HUMAN RESOURCES SPECIALIST
OFFICE OF HUMAN RESOURCES
U.S. NUCLEAR REGULATORY COMMISSION
WASHINGTON, DC 20555-0001

CONFIRMED DATES OF EMPLOYMENT (From-To)

SUPERIOR

NAME OF APPLICANT

This form is used for investigating the qualifications of external applicants for appointment. The applicant should
not be rated on those items which have been lined out by the Human Resources Specialist as not applicable.
Additional comments can be provided on the reverse side.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

Technical competence
Effectiveness in making decisions or recommendations
Ability to comprehend problems
Extent to which applicant keeps abreast of new developments
Effective use of equipment, materials, and techniques related to work
Thoroughness and objectivity in carrying out work
Ability to identify priorities and organize work
Ability to meet deadlines
Ability to supervise
Ability to establish effective work relationships with:
a. Subordinates
b. Co-workers
c. Higher level officials
d. Representatives of industry or other government agencies
Oral expression
Written expression
Adaptability
Effectiveness in training and developing subordinates
Dependability/Reliability
Quality of work
Initiative (Is applicant a self-starter?)
Creativity (Can applicant think outside the box?)
Amount of work produced
Ability to work effectively in stressful situations
Work habits
How would you rate applicant in regard to potential for filling position for which applied?
Have you any reason to question this applicant's trustworthiness or loyalty to the U.S.A.?

NO BASIS

The applicant named below has applied for a position in the NRC. Please rate the applicant against the items below in
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.

BELOW
AVERAGE

(other than clerical positions)

AVERAGE

QUALIFICATIONS INVESTIGATION
PROFESSIONAL, TECHNICAL, AND
ADMINISTRATIVE POSITIONS

ABOVE
AVERAGE

NRC FORM 212
(3-2007)
NRC MD 10.1

Yes (Explain)

No

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

Yes (Explain)

No

25. Would you rehire this applicant? (If applicable, check one)

Yes

N/A

26. Relationship to Applicant

Supervisor

Co-Worker

Professional

No

Other (Specify)

ADDITIONAL COMMENTS (Continue on reverse.)

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. Please indicate below whether you desire your identity be kept confidential.

My identity may be revealed.
NAME OF REVIEWER

NRC FORM 212 (3-2007)

I request my identity be kept confidential.
SIGNATURE - REVIEWER

DATE

PRINTED ON RECYCLED PAPER