NSTC 1533-156 (07- Teacher Evaluation

OMB Control Number: 0703-0026, Exp _______________
AGENCY DISCLOSURE STATEMENT
The public reporting burden for this collection of information is estimated to average 3 hours and 30 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate,
Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (OMB Control Number: 0703-0026).
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.
Responses should be sent to:
Commander
Naval Service Training Command
2601 A Paul Jones Street
Great Lakes, IL 60088
PLEASE READ THE FOLLOWING STATEMENT REQUIRED BY THE PRIVACY ACT OF 1974 BEFORE COMPLETING THE
APPLICATION.
1.AUTHORITY: The authority to request this information is contained in: 5 U.S.C. § 301 (Authorizing Departmental Forms and Regulations); 10
U.S.C. § 2107 (Financial Assistance Program); and Executive Order 9397 (Use of Social Security Numbers).
2.PRINCIPAL PURPOSE(S): The information you provide will be used to determine whether you qualify, and should be nominated for, an
NROTC Scholarship. If you are nominated, the information will be used to enroll you into NROTC and will be used by the Navy in its
management of the NROTC program. The following systems of records notices cover the collection of this information: N01130-1 located at
http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570316/n01130-1.aspx.
3.ROUTINE USE(S): Information provided on the application will be used to screen and select individuals to received NROTC Scholarships, to
maintain data on the NROTC scholarship program, to compare to scholarship applicants from previous or subsequent years, and to provide
academic data and contact information to Navy activities and admissions officials at colleges and universities so they can contact applicants for
recruitment purposes. Other uses may include providing the information to officials and employees of: the Department of Transportation; other
agencies of the Executive Branch upon request in relation to the management of quality of military recruitment; and the Department of Veterans
Affairs and Selective Service Administration in relation to enlistment or reenlistment eligibility. Information you provide in this application is
protected by the Privacy Act and will not be released outside of the Department of Defense without your permission unless it comes with an
exception to the Act or one of the routine uses in 32 C.F.R. § 701.112, http://www.privacy.navy.mil/ and the routine uses set forth here. If you are
nominated for an NROTC Scholarship, the information will be released to the top five schools you indicated on your application. Your
information and notification of status may also be provided to your high school so they may assist with the final stages of the process.
4.DISCLOSURE: The social security number (SSN) is required at the time of application to ensure proper identification of the applicants. There
are times applicants have the same names, therefore the SSN is required to ensure proper identification. Providing the requested information is
voluntary. However, failure to do so may result in our inability to process your application for the NROTC program.

NSTC 1533/156 (07-16)

MATH / SCIENCE / ENGLISH TEACHER EVALUATION OF APPLICANT
Applicant’s Last Name: ____________________________First Name: _________________ MI: _____
Social Security Number: _____________________________
INSTRUCTIONS FOR THE SCHOOL OFFICIAL: Please evaluate the following statements concerning
the above named applicant. Mark only one choice for each statement. Rate the statements on how well
the quality describes the applicant in relation to his/her peers.
Your identity as the source of information relating to the applicant will be disclosed upon the applicant’s
request, unless you require confidentiality as a condition of furnishing any information. In such case,
your identity will be held in confidence.
Do you stipulate confidentiality as a condition for providing this information? YES/NO
Statement

Top
1%

Top
10%

Above
Average

Average

Below
Average

Not
Observed

1. Works toward group goals when in a
subordinate position
2. Gains respect of peers
3. Influences other students to work together
4. Communicates effectively in face to face
discussion
5. Communicates effectively in written work
6. Exerts maximum effort showing a strong
desire to achieve in every field
7. Sets high standards for own performance in
a number of areas of activity
8. Accepts criticism and makes improvements
from it
9. Adjusts to a demanding schedule of
activities without neglecting school work
10. Makes friends easily
11. Persists when solving problems
12. Demonstrates intellectual curiosity
How would you rate this student among all
that you have taught?

How long have you known this student? _________________________

NSTC 1533/156 (07-16)

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Did you provide this student with any academic accommodations? (i.e., requires extra time on test,
established 504 plan) YES ________ NO __________
If yes, please list the type of academic accommodation and the school year/s received.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
REMARKS: This form must be completed by only an English or Math instructor. (If student is Nursing
Option, form must be completed by only an English or Science instructor.) Please tell us how you feel
this student will perform in a demanding academic environment. If would also be helpful if you would
comment on the student’s character and integrity as compared to that of his/her peers. Math teacher
comments are strongly desired on student’s potential for completing calculus and calculus-based physics.
Thank you for your concern, time and cooperation.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please indicator the type of instruction you provide
English Instructor _______

Math Instructor ______

Science Instructor _________

_____________________________________

___________________

Signature of Evaluator

Date

____________________________________

____________________

Printed Name of Evaluator

Phone Number

NSTC 1533/156 (07-16)

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