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

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 212
(MM-DD-YYYY)
NRC MD 10.1

QUALIFICATIONS INVESTIGATION
PROFESSIONAL, TECHNICAL, AND
ADMINISTRATIVE POSITIONS

APPROVED BY OMB: NO. 3150-0033

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory information collection request:
30 minutes. This information is used to determine the qualifications and suitability of external
applicants for employment. Send comments regarding burden estimate to the FOIA, Library,
and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and the OMB
reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0033), Attn: Desk
Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503;
email: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless the document requesting or
requiring the collection displays a currently valid OMB control number.

The applicant named below has applied for a position in the NRC. Please rate the applicant in the items listed below with 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.
Name of Applicant:

Position for which applied:

To: (Name and title of supervisor or reference

From:

Human Resources Specialist
Office of the Chief Human Capital Officer
U. S. Nuclear Regulatory Commission
Washington, DC 20555

Applicant's position with your company:

Confirmed Dates of Employment
Start Date (MM/DD/YYYY)

End Date (MM/DD/YYYY)

TECHNICAL AREA:
Above Average

Average

Below Average

Above Average

Average

Below Average

Above Average

Average

Below Average

How would you rate the applicant's knowledge of the work?

How well did the applicant perform the duties of the position?

How well did the applicant manage the workload?

What were his/her strengths?

What were his/her weaknesses?

NRC FORM 212 (MM-DD-YYYY)

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NRC FORM 212

(MM-DD-YYYY)
NRC MD 10.1

U.S. NUCLEAR REGULATORY COMMISSION

QUALIFICATIONS INVESTIGATION PROFESSIONAL, TECHNICAL, AND
ADMINISTRATIVE POSITIONS (Continued)

CHARACTERISTICS:
Above Average

Average

Below Average

Above Average

Average

Below Average

Was the applicant dependable?

How did the applicant work in stressful situation?

How would you describe the applicant's relationship with:
Co-workers?

Supervisors?

Higher Officials?

REQUIRED QUESTIONS:
1. Have you any reason to question this applicant's trustworthiness or loyalty to the U. S.?

Yes

No

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

Yes

No

3. Is this applicant eligible for re-hire in your organization?

Yes

No

Relationship to Applicant:

Supervisor

Co-worker

Professional

Other (Specify):

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.
My Identity May be Revealed

I Request My Identity be kept Confidential

Typed Name and/or Title of Interviewer

Signature of Interviewer

Additional Comments

NRC FORM 212 (MM-DD-YYYY)

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