DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS (DoDDS) PROFESSIONAL EVALUATION Form Approved OMB No. 0704-0370 Expires Jun 30, 200 I 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. If information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Report: 0704.0:'01, 1215 Jefferson Davis Highway, Suite 1234, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failure to comply with a collection of information if it does not display a currently valid DMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO ADDRESS IN ITEM 14. AUTHORITY: 20 USC Sections 902, 903, and E.O. 9397. PRINCIPAL PURPOSE: Used to screen applications for qualifications eligibility. PRIVACY ACT STATEMENT ROUTINE USE: None. DISCLOSURE: Voluntary. Personal identifier data is requested solely to provide positive identification of applicant. However, failure to provide the requested identification information may cause delay in evaluating the candidate for position vacancies. (Name and Social Security Number) _________________________ is an applicant for a position with the Department of Defense Overseas Dependents Schools. 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. USE ITEM 10 TO ELABORATE ON ANY OF THESE ITEMS. I. WHAT YEARS DID YOU OBSERVE THIS APPLICANT'S WORK? (From - To) 2. WHAT WAS YOUR POSITION AT THE TIME OF THIS OBSERVATION? 3. PLEASE MARK IXI ITEMS BELOW OF WHICH YOU HAVE KNOWLEDGE: EXEMPLARY HIGH DEGREE MEETING LEVEL LESS THAN DOES NOT MEET LEVEL DIVISION STANDARDS 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. EMOTIONAL STABILITY l. DEPENDABILITY m. CONDUCT/REPUTATION IN THE COMMUNITY n. COMMITMENT TO CHILDREN 4. HOW DO YOU RATE THIS APPLICANT IN OVERALL PROFESSIONAL ABILITY? Poor, Fair, Average, Good, Superior 5. WOULD YOU UNHESITATINGLY EMPLOY OR RE-EMPLOY THIS CANDIDATE? YES, NO 6. DO YOU HAVE ANY REASON TO QUESTION THIS CANDIDATE'S LOYALTY TO THE UNITED STATES? YES, NO 7. TO YOUR KNOWLEDGE HAS THIS APPLICANT EVER BEEN ASSOCIATED WITH ANY PERSON WHOSE LOYALTY TO THE UNITED STATES IS QUESTIONABLE OR WHO BELONGS TO ANY OF THE TYPES OF ORGANIZATIONS DESCRIBED IN THE PRECEDING QUESTION? YES NO 8. 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 9. 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 10.) YES, NO DS FORM 5011, JUN 1998 REPLACES SD FORM 778, SEP 91, WHICH IS OBSOLETE. Designed using Perform Pro, WHSIDIDR, Jun 98 PROFESSIONAL EVALUATION (Continued) 10. 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. 11. NAME AND ADDRESS OF YOUR SCHOOL 12. TYPED NAME, SIGNATURE, POSITION OR TITLE OF EVALUATOR 13. DATE (YYYYMMDD) 14. RETURN THIS INQUIRY TO: DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS RECRUITMENT UNIT 4040 NORTH FAIRFAX DRIVE ARLINGTON, VA 22203-I 634 DS FORM 5011 (BACK), JUN 1998