Group Assessment Form

GROUP ASSESSMENT FORM

OMB CONTROL NUMBER: XXXX-XXXX
XXXXXX-XXXX
OMB EXPIRATION DATE: XX/XXXX/XXXX
XXXX-XXXX

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The public reporting burden for this collection of information,insert
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Version 1.1 – Effective 7/18/2017

GROUP ASSESSMENT FORM

Group Name (Board, GSC, Compensation, etc.):
Company and CAGE:

1. How is the Company’s Board/Committee composed, and how does that composition affect corporate
culture, group dynamics, and Shareholder engagement?
please explain

D

A
R

T
F

2. How does the group intend to address any shortcomings that exist within the group?
please explain

3. How would you characterize the group’s overall effectiveness this assessment cycle?
select one
please explain

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4. How would you characterize the group’s engagement and relationship with the C Suite of the
Company?
select one

please explain

5. How would you characterize the group’s engagement and relationship with the ultimate foreign
shareholder?
select one
please explain

D

A
R

T
F

Signature:

Date:

E-mail:

Phone:

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PENDING OMB APPROVAL