DoDEA Form 5011 Department of Defense Dependents Schools (DoDDS) Profess

CUI (When Filled In)

DEPARTMENT OF DEFENSE EDUCATION ACTIVITY (DoDEA)
PROFESSIONAL EVALUATION

OMB No.: 0704-0370
OMB approval expires:

The public reporting burden for this collection of information is estimated to average 20 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, Information Management Division, 4800 Mark Center
Drive, Alexandria, VA 22350-3100 (0704-0370). 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 FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO ADDRESS IN ITEM 14.
PRIVACY ACT STATEMENT
AUTHORITY: 20 U.S.C. Sections 902, 903, and 921-932; and E.O. 9397 SSN, as amended.
PRINCIPAL PURPOSE: To obtain pertinent supervisory evaluation information about an applicant from prior employer of applicant to assist management in
making a hiring decision. Information is covered by OPM/GOVT-5, "Recruiting Examining and Placement Records," https://www.opm.gov/informationmanagement/privacy-policy/sorn/opm-sorn-govt-5-recruiting-examining-and-placement-records.pdf. Upon entry into Federal service the form is maintained
under OPM/GOVT-1, "General Personnel Records," https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-1-general-personnelrecords.pdf.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the information may be
disclosed outside the DoD pursuant to 5 U.S.C. 552a(b)(3). To disclose to appropriate Federal officials pertinent workforce information for use in national or
homeland security emergency/disaster response. Additional routine uses are listed in the applicable System of Records Notice: OPM/GOVT-1, General
Personnel Records at: https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-1-general-personnel-records.pdf.
DISCLOSURE: Voluntary; however, failure to provide the requested information may delay or prevent the processing of an application for a teaching position.

SECTION I
(Applicant Name and Social Security Number)
SECTION II
The above named individual is an applicant for employment with the Department of Defense Education Activity (DoDEA). The data that you provide
will assist DoDEA in making a hiring decision. The information you provide, including your identity, will be disclosed to the above named person, and to
other Federal, State and local agencies, at his or her request, or as otherwise authorized by the Privacy Act of 1974, as amended, 5 U.S.C. 552a. It is
important that persons selected for these assignments have abilities and personal traits which give promise of outstanding success under the unusual
circumstances they will meet abroad. The success of the United States Government in maintaining prestige in foreign countries also depends upon the
right choice of candidates. To complete one phase of the screening, therefore, we would like to have your frank judgment of the applicant's personality
and professional ability. Your assistance as soon as possible will be greatly appreciated. Under the Freedom of Information and Privacy Acts, a copy
of this completed form must be released to the candidate for employment if requested. This form should be completed within 5 days and
mailed directly to the address shown in Item 14, or to the candidate, as appropriate.

D R A F T

USE ITEM 8 TO ELABORATE ON ANY OF THESE ITEMS.
1. PLEASE MARK (X) ITEMS BELOW OF WHICH YOU HAVE KNOWLEDGE:
EXEMPLARY
LEVEL

HIGH DEGREE MEETING
DIVISION STANDARDS

LEVEL LESS THAN
DOES NOT MEET
PROFESSIONALLY EXPECTED JOB REQUIREMENT

a. GENERAL KNOWLEDGE/COMPETENCE IN FIELD
b. POTENTIAL EFFECTIVENESS IN THIS JOB
c. ABILITY TO MAINTAIN DISCIPLINE
d. INITIATIVE
e. WRITTEN COMMUNICATION SKILLS
(Language usage, etc.)
f. ORAL COMMUNICATION SKILLS
g. RESPONSIBILITY
h. PROFESSIONAL IMPROVEMENT
i. ABILITY TO GET ALONG WITH OTHERS
j. OVERALL APPEARANCE
k. DEPENDABILITY
l. CONDUCT/REPUTATION IN THE COMMUNITY
m. COMMITMENT TO CHILDREN

2. HOW DO YOU RATE THIS APPLICANT IN OVERALL PROFESSIONAL ABILITY?
POOR

FAIR

AVERAGE

3. WOULD YOU EMPLOY OR RE-EMPLOY THIS CANDIDATE?
(If No, please explain in Item 8.)
YES

NO

GOOD

SUPERIOR

4. DO YOU HAVE ANY REASON TO QUESTION THIS CANDIDATE'S
LOYALTY TO THE UNITED STATES?
YES

NO

5. TO YOUR KNOWLEDGE HAS THIS APPLICANT EVER BEEN ASSOCIATED WITH ANY PERSON WHOSE LOYALTY TO THE UNITED STATES
IS QUESTIONABLE?
YES

NO

DoDEA Form 5011, MONTH YEAR

PREVIOUS EDITIONS ARE OBSOLETE.

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CUI (When Filled In)
6. DO YOU HAVE ANY KNOWLEDGE OF ANY BEHAVIOR, ACTIVITIES OR ASSOCIATIONS WHICH TEND TO SHOW THAT THIS CANDIDATE
IS NOT RELIABLE, HONEST, TRUSTWORTHY AND OF GOOD CONDUCT AND CHARACTER?
YES

NO

7. DO YOU HAVE ANY KNOWLEDGE OR SUSPICIONS THAT THIS INDIVIDUAL MAY HAVE ENGAGED IN ANY FORM OF CHILD ABUSE?
(If Yes, please explain in Item 8.)
YES

NO

8. PLEASE GIVE A FRANK STATEMENT EMPHASIZING PARTICULAR STRENGTHS AND/OR WEAKNESSES CONCERNING THIS
CANDIDATE'S TOTAL TEACHING ABILITY; LEADERSHIP QUALITIES; INTELLECTUAL AND SCHOLASTIC CHARACTERISTICS;
AND ABILITY TO WORK WITH CHILDREN AND PARENTS.

D R A F T

9. WHAT YEARS DID YOU OBSERVE THIS APPLICANT'S WORK? 10. WHAT WAS YOUR POSITION AT THE TIME OF THIS OBSERVATION?
(From - To)
11. NAME AND ADDRESS OF YOUR SCHOOL

12. TYPED NAME, SIGNATURE, POSITION OR TITLE OF EVALUATOR

14. RETURN THIS INQUIRY TO:

13. DATE (YYYYMMDD)

Civilian Human Resources Agency (CHRA)
DoDEA Recruitment Cell, North Central Region
ATTN: CHRA-NCR-K
1 Rock Island Arsenal, Building 104, Rock Island, IL 61299-7650

DoDEA FORM 5011 (BACK), MONTH YEAR

Controlled By: DoDEA
Category: PERS
LDC: CHRA
POC: HR Policy & Compliance Branch

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