Self-Assessment Form

SELF ASSESSMENT FORM

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

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information,insert
[InsertOMB
OMB
Control
Number], is estimated to
Control
Number
average 45 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 the burden estimate or burden reduction sug-gestions to the Department of Defense,
Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-infor-mation-collections@mail.mil.
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.

Version 1.1 – Effective 7/18/2017

SELF-ASSESSMENT FORM

Name:
Role with the Company: Select
Company and CAGE:

1. Which areas of expertise did you utilize during this assessment period?
national security
finance

information security

business development

business operations

technology

personnel security

cybersecurity
other

industrial security

network operations

T
F

acquisition

2. How would you assess your overall effectiveness fulfilling your fiduciary duties to the Company during
this assessment period?
select one

please explain

A
R

3. How would you assess your overall effectiveness fulfilling your duty to protect national security
information?
select one

please explain

D

4. How would you assess your understanding of the threat to the company’s critical technologies, assets,
and information?
select one
please explain

5. How and from whom do you receive the threat information?
please explain

PENDING OMB APPROVAL

PAGE | 1

6. How would you characterize your understanding of the vulnerabilities to the company’s critical technologies,
assets, and information?
select one

please explain

7. How and from whom do you receive information on vulnerabilities?
please explain

T
F

8. How would you characterize your professional relationship with the following groups or individuals?
select one

select one

select one

select one

select one

select one

select one

select one

select one

select one

please explain as necessary

D

A
R

9. What are areas for improvement in your performance of your fiduciary and national security duties during the
next assessment period, and how do intend to sustain or improve your level of performance?
please explain as necessary

Signature:

Date:

E-mail:

Phone:

2 | PAGE

PENDING OMB APPROVAL