Brevard Public Schools

THE FUTURE OF FLORIDA'S SPACE COAST

SCHOOL BOARD OF BREVARD COUNTY DEPARTMENT OF HUMAN RESOURCES SERVICES 2700 JUDGE FRAN JAMIESON WAY VIERA, FLORIDA 32940-6699

INSTRUCTIONS FOR ALL APPLICANTS

Thank you for your interest in Brevard Public Schools. Please read the following instructions carefully. Complete your employment application and return the signed original to Human Resources Services. Complete and sign Section A on the appropriate side of the reference forms and send them to persons providing references. Completed applications will remain active for one year. It is your responsibility to complete an addendum, at one year intervals, to remain an active candidate for employment. Falsification of information or failure to fully disclose information may result in rejection of the application or dismissal if you become employed. All applicants should refer to the personnel hiring policy regarding arrests, convictions and other court adjudications as listed on the back of this page. PLEASE PRINT IN BLUE INK OR TYPE! Your application package is complete when all of the following original items are received in Human Resources Services (faxed copies are not acceptable): • Completed original Employment Application

• Verification of High School Diploma (if applicable), or • Complete Official Transcript(s) of all college credits (two sets are required for teacher applicants)

• Copy of your Social Security card with correct name • Signed original references - a minimum of three work-related references are required. A reference from your most recent employment will be required. Additional references may be required by Human Resources Services. Acceptable references are from principals, supervisors, and managers. Completeness of your application should be verified by calling (321) 631-1911, ext. 225, 226, or 227

For all current vacant positions, job descriptions, salary schedules and other district information, access Brevard Public Schools’ homepage at www.brevard.k12.fl.us. All vacant positions are posted on our district website, at our schools and Human Resources Services, ESF, Viera. Instructional positions are recorded on our 24 hour jobline: (321) 633-3519. • When a position is advertised for which you are qualified, contact the administrator directly for further information about the position. That administrator reviews the applicant files and schedules interviews for selected candidates. • Upon nomination for employment, prerequisites will include a drug screen test and fee and fingerprints and fee for law enforcement records check. Fingerprints must be done at the school district’s Office of District and School Security located at ESF, Viera. Hours are Monday through Thursday 8:30am-3:00pm. A preemployment medical examination will be required for all custodians and delivery drivers. • All applicants for substitute positions should request the additional forms for substitute employment. These forms may be picked up at any one of the district's schools or at Human Resources Services at ESF in Viera. References from three most recent supervisors are required. • Applicants are NOT required to have a High School Diploma to be employed in the following positions: Baker • Cook • Custodian • Cafeteria Worker • Bus Driver • Cafeteria Cashier • Standby Driver If an applicant is hired in one of the above classifications and later wants to apply for a position that requires a diploma, proof of a High School Diploma must be provided to meet the qualifications of the new position. • CERTIFICATION AND TRAINING FOR INSTRUCTIONAL PERSONNEL: Instructional personnel must be eligible for a Florida Educator's Certificate. Application for the Florida Teaching certificate should be submitted to the Department of Education in Tallahassee. Copies of any communication received from the Department of Education should be forwarded to Human Resources Services. Teachers will be required to sign the District Agreement to complete ESOL inservice training. Part-time adult/community education and non-degreed vocational teachers will be required to apply for a district certificate upon employment. The appropriate forms are available from Human Resources Services. If you have questions regarding certification, you may call (321) 631-1911 ext. 210 & 212.

9400-F200-04-04

A DRUG-FREE WORKPLACE AN EQUAL OPPORTUNITY EMPLOYER

SCHOOL BOARD OF BREVARD COUNTY 2700 JUDGE FRAN JAMIESON WAY VIERA, FLORIDA 32940-6699 (321) 631-1911

Brevard Public Schools

THE FUTURE OF FLORIDA'S SPACE COAST

APPLICATION FOR EMPLOYMENT

A

If you need an accommodation to participate in the application/selection process, please notify Human Resources in advance.

PERSONAL DATA - ALL APPLICANTS COMPLETE

APPLICATION DATE (Month, Day, Year)

SOCIAL SECURITY NUMBER CURRENT NAME: LAST

FIRST

FORMER NAME: LAST PRESENT ADDRESS STREET

MIDDLE

DATE OF BIRTH (M/D/Y) APT #

CITY PERMANENT ADDRESS STREET

STATE

CITY

STATE

PHONE (

ZIP+4 APT # ZIP+4

)

E-Mail Address: EXT Have you been employed by the School Board of Brevard County in the past? Are you a retiree of the School Board of Brevard County? If YES:

YES

NO

YES

NO

Position (Title)

School/Department Date: From (M/D/Y)

To (M/D/Y)

Under What Last Name

The following information is Voluntary. SEX: Male

RACE: White, Non-Hispanic

Female

Black, NonHispanic

American Indian/ Alaskan Native

Asian/Pacific Islander

Hispanic

Are you under 18 years of age? If YES, what was your age on your last birthday?

YES

NO

Are you a citizen of the United States?

YES

NO

Do you wish to claim Military Veteran's Preference? If YES, please complete the Veterans' Preference claim form.

YES

NO

YES

NO

YES

NO

Are you retired from a Florida State Administered Retirement System? Do you have any relatives, including elected officials, by blood or marriage working for the School Board of Brevard County? If YES, the information requested below is required. (PLEASE ATTACH A SEPARATE SHEET IF YOU NEED MORE SPACE.)

RELATIVE'S NAME: LAST

FIRST

RELATIONSHIP

SCHOOL/DEPARTMENT

B

MIDDLE

EMPLOYMENT DATA - ALL APPLICANTS COMPLETE

Area of District Preferred:

NORTH

INSTRUCTIONAL POSITIONS

CENTRAL

SOUTH

ANY

DATE YOU ARE AVAILABLE (M/D/Y)

(Eligibility for Florida Educator's Certificate or District Certificate is required)

Check all areas that apply.

Guid. Couns. ____ Pre-Kindergarten ___ Subject Substitute Media Spec. ____ Kindergarten ___ __________________ Administration ____ Technology Ed. ____ Elementary (Grd 1-3) ___ __________________ Substitute Teacher ___ Adult Education ____ Vocational Ed. ____ Elementary (Grd 4-6) ___ __________________ Classroom Assistant ___ Community Coach ____ Exceptional Ed. ____ Middle (Grd 6-8) ___ __________________ Substitute Support ___ Ex. Curricular Sponsor ____ Foreign Language ____ Senior High (Grd 9-12) ___ __________________ Other Instruction _______________________________________________________________________________________________________________ NON-INSTRUCTIONAL POSITIONS If you have experience in a specific area or are applying for a specific job, please indicate in the space below general category. Accounting/Finance _________________ _________________________________ Clerical ___________________________ _________________________________ Data Processing ____________________ _________________________________ Equipment Repair ___________________ _________________________________ Florida Driver's License Number Type:

Regular _____

CDL _____

Maintenance/Construction/Trades ______________ _________________________________________ Materials Distribution ________________________ _________________________________________ Mechanical Repair __________________________ _________________________________________

Bus Driver Custodian Food Services Printing Instr. Asst.

Date of Birth (M/D/Y) Expiration Date (M/D/Y)

Class _____ Endorsements

SKILLS/SPECIAL ABILITIES Trades (Please List) Professional Licenses or Certifications (Please List) Foreign Languages (Please List) Shorthand Bookkeeping Typing Speed (WPM) Data Entry Word Processing Programming

Expiration Date(s) (M/D/Y) Switchboard Sign Language HRS Child Care

A DRUG-FREE WORKPLACE • AN EQUAL OPPORTUNITY EMPLOYER

Child Development Associate

C

ACADEMIC RECORD - (ALL APPLICANTS)

EDUCATION AND SPECIAL TRAINING Check the highest grade you completed in school:

NAME

1

2

3

4

5

6

7

8

9

10

11

12

ASSOC

BACH

DIPLOMA GRADUATION GPA ATTENDANCE DATES DEGREE DATE (M/Y)

LOCATION

MAST

SPEC

MAJOR

DOCT

SEM HRS

From (M/Y) HIGH SCHOOL

To (M/Y) From (M/Y) To (M/Y) From (M/Y)

COLLEGE/ UNIVERSITY

To (M/Y) From (M/Y) To (M/Y) From (M/Y) To (M/Y) From (M/Y)

OTHER EDUCATION

NOTE:

D

To (M/Y)

APPLICANTS ARE RESPONSIBLE FOR PROVIDING COPIES OF HIGH SCHOOL DIPLOMAS AND TRAINING CERTIFICATES. APPLICANTS ARE RESPONSIBLE FOR REQUESTING OFFICIAL TRANSCRIPTS FROM ALL COLLEGES AND UNIVERSITIES.

NON-TEACHING EMPLOYMENT EXPERIENCE - ALL APPLICANTS COMPLETE Begin with the most recent and include reason for any break in employment.

FROM (M/D/Y) ____

___

___

TO (M/D/Y) ______

___

___

FULL TIME ❏

PART TIME ❏

EMPLOYER _____________________________________________ ADDRESS STREET ___________________________________________________ CITY ___________________________________________________ STATE _______ ZIP+4 _______

_____

JOB TITLE ______________________________________________________ LAST SALARY (MONTH OR HR)

PHONE ( ___ ) _____ - _____ , ext. __

________________________________________________

JOB DUTIES __________________________________________________________________________________________________________________ REASON FOR LEAVING ________________________________________________________________________________________________________ SUPERVISOR NAME: LAST ________________________________________ FIRST _________________________ TITLE ______________________ FROM (M/D/Y) ____

___

___

TO (M/D/Y) ______

___

___

FULL TIME ❏

PART TIME ❏

EMPLOYER _____________________________________________ ADDRESS STREET ___________________________________________________ CITY ___________________________________________________ STATE _______ ZIP+4 _______

_____

JOB TITLE ______________________________________________________ LAST SALARY (MONTH OR HR)

PHONE ( ___ ) _____ - _____ , ext. __

________________________________________________

JOB DUTIES __________________________________________________________________________________________________________________ REASON FOR LEAVING ________________________________________________________________________________________________________ SUPERVISOR NAME: LAST ________________________________________ FIRST _________________________ TITLE ______________________ FROM (M/D/Y) ____

___

___

TO (M/D/Y) ______

___

___

FULL TIME ❏

PART TIME ❏

EMPLOYER _____________________________________________ ADDRESS STREET ___________________________________________________ CITY ___________________________________________________ STATE _______ ZIP+4 _______

_____

JOB TITLE ______________________________________________________ LAST SALARY (MONTH OR HR)

PHONE ( ___ ) _____ - _____ , ext. __

________________________________________________

JOB DUTIES __________________________________________________________________________________________________________________ REASON FOR LEAVING ________________________________________________________________________________________________________ SUPERVISOR NAME: LAST ________________________________________ FIRST _________________________ TITLE ______________________ FROM (M/D/Y) ____

___

___

TO (M/D/Y) ______

___

___

FULL TIME ❏

PART TIME ❏

EMPLOYER _____________________________________________ ADDRESS STREET ___________________________________________________ CITY ___________________________________________________ STATE _______ ZIP+4 _______

_____

JOB TITLE ______________________________________________________ LAST SALARY (MONTH OR HR)

PHONE ( ___ ) _____ - _____ , ext. __

________________________________________________

JOB DUTIES __________________________________________________________________________________________________________________ REASON FOR LEAVING ________________________________________________________________________________________________________ SUPERVISOR NAME: LAST ________________________________________ FIRST _________________________ TITLE ______________________ PLEASE ATTACH ADDITIONAL SHEETS IF NEEDED.

E

STUDENT TEACHING (INTERNSHIP) EXPERIENCE - (IF APPLICABLE) TO (M/D/Y)

FROM (M/D/Y) SCHOOL

ADDRESS STREET

CITY

STATE

ZIP+4

SUPERVISING TEACHER NAME: LAST PHONE (

)

FIRST EXT GRADE LEVEL

SUBJECT

FIRST

COLLEGE SUPERVISOR NAME: LAST TO (M/D/Y)

FROM (M/D/Y) SCHOOL

ADDRESS STREET

CITY

STATE

ZIP+4

SUPERVISING TEACHER NAME: LAST PHONE (

)

FIRST EXT GRADE LEVEL

SUBJECT COLLEGE SUPERVISOR NAME: LAST

FIRST PLEASE ATTACH ADDITIONAL SHEETS IF NEEDED.

F

TEACHING EXPERIENCE UNDER CONTRACT - (IF APPLICABLE) FULL TIME

TO (M/D/Y)

FROM (M/D/Y) SCHOOL

ADDRESS STREET

CITY

STATE

PART TIME ZIP+4 FIRST

ADMINISTRATOR/PRINCIPAL NAME: LAST EXT PHONE ( ) GRADE LEVEL

SUBJECT

NUMBER OF YEARS

REASON FOR LEAVING FROM (M/D/Y)

FULL TIME

TO (M/D/Y)

SCHOOL

ADDRESS STREET

CITY

STATE

PART TIME ZIP+4 FIRST

ADMINISTRATOR/PRINCIPAL NAME: LAST PHONE (

)

EXT GRADE LEVEL

SUBJECT

NUMBER OF YEARS

REASON FOR LEAVING FROM (M/D/Y)

FULL TIME

TO (M/D/Y)

SCHOOL

ADDRESS STREET

CITY

STATE

PART TIME ZIP+4 FIRST

ADMINISTRATOR/PRINCIPAL NAME: LAST EXT PHONE ( ) GRADE LEVEL

SUBJECT

NUMBER OF YEARS

REASON FOR LEAVING FROM (M/D/Y)

FULL TIME

TO (M/D/Y)

SCHOOL

ADDRESS STREET

CITY

STATE

PART TIME ZIP+4

ADMINISTRATOR/PRINCIPAL NAME: LAST PHONE (

)

SUBJECT

FIRST

EXT GRADE LEVEL

NUMBER OF YEARS

REASON FOR LEAVING PLEASE ATTACH ADDITIONAL SHEETS IF NEEDED.

G

INSTRUCTIONAL CERTIFICATION - (IF APPLICABLE)

Do you currently hold a valid Florida Educator's Certificate?

YES

NO

Have you applied for a Florida Educator's Certificate?

YES

NO

YES

NO

YES

NO

If YES, when (M/D/Y)

and what subject(s)?

Have you ever had a teaching certificate suspended or revoked by the state of Florida or any state? If YES, attach a written explanation. Are you under contract with any school system at the present time? If YES, name the school system. List other states in which you hold a valid teaching certificate. PLEASE PROVIDE A COPY OF ANY VALID CERTIFICATE THAT YOU HOLD.

H

OTHER INFORMATION - ALL APPLICANTS COMPLETE

A.

SEALED/EXPUNGED RECORD Have you ever been convicted or found guilty of a criminal offense other than a minor traffic violation (DUI is NOT a minor traffic violation) and such record(s) was sealed or expunged? A YES or NO answer is required by Florida Law. YES

B.

ARREST RECORD Have you ever been arrested and/or convicted, found guilty, had adjudication withheld, or entered a plea of nolo contendere (no contest) to a crime other than a minor traffic violation? (DUI is NOT a minor traffic violation) Florida Law requires a YES or NO answer. Please attach a certified copy of legal disposition and/or court document related to each arrest. Any record that has NOT been SEALED or EXPUNGED must be reported in this section.

IF YOU CHECKED YES, YOU MUST GIVE THE INFORMATION REQUESTED FOR EACH CHARGE. YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION BEING PROVIDED. PLEASE ATTACH A SEPARATE SHEET IF YOU NEED MORE SPACE. STATE CHARGE(S) CITY DATE OF ARREST

YES

NO

NO

DISPOSITION(S)

(M/D/Y)

BUS DRIVERS AND MAINTENANCE APPLICANTS ONLY Are you licensed to drive in Florida? Have you at any time during the past three years, been charged with a traffic violation?

YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION BEING PROVIDED. IF YOU CHECKED YES, YOU MUST GIVE THE INFORMATION REQUESTED FOR EACH CHARGE. PLEASE ATTACH A SEPARATE SHEET IF YOU NEED MORE SPACE. STATE CHARGE(S) CITY DATE OF VIOLATION

YES

NO

YES

NO

DISPOSITION(S)

(M/D/Y)

I

AGREEMENT - ALL APPLICANTS COMPLETE

I hereby represent that each answer to a question herein and all other information otherwise furnished is true, complete, and correct. I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer of information relates. I understand that any incorrect, incomplete, or false statements or information furnished by me will subject me to discharge at any time. In the event that I am employed by the SCHOOL BOARD OF BREVARD COUNTY, I agree to comply with all its orders, rules, and regulations. I hereby authorize my former employers to give any information regarding my employment with them and, in addition, to furnish any other information they have concerning me. I understand that I will participate in a drug screening when offered employment and that I must have negative drug screen results to be employed. If my drug screen is positive, I understand that I may not be considered for employment for one (1) year after the date of the positive test. I understand that I will be fingerprinted as a matter of protection and identification, and will be on probationary status pending fingerprint processing and payment of fees associated with the fingerprint process. I will have a physical exam by a qualified physician if required as a condition of employment. I authorize the release of all information from any and all law enforcement agencies where protected under the Privacy Act. All information contained in the applicant's file is public information subject to inspection under the Public Records Act, Florida Statute 119.07, unless specifically excluded from the Public Records Act, under Florida School Law 1012.31. It is the policy of the SCHOOL BOARD OF BREVARD COUNTY not to discriminate against employees or applicants for employment on the basis of race, color, religion, sex, national origin, marital status, age, or disability. Sexual harassment is a form of employee misconduct which undermines the integrity of the employment relationship, and is prohibited. This policy shall apply to recruitment, employment, transfers, compensation, and other terms and conditions of employment. My signature signifies that I have read this Agreement and fully understand its contents. SIGNATURE PER 9400 006 04/04

DATED

SCHOOL BOARD OF BREVARD COUNTY DEPARTMENT OF HUMAN RESOURCES SERVICES

Brevard Public Schools

2700 JUDGE FRAN JAMIESON WAY VIERA, FLORIDA 32940-6699

THE FUTURE OF FLORIDA'S SPACE COAST

INSTRUCTIONAL APPLICANT REFERENCE FORM SECTION A - NOTE: Applicant completes SECTION A, Reference completes SECTIONS B and C APPLICANT'S NAME I have applied for an instructional position with the SCHOOL BOARD OF BREVARD COUNTY in the following area(s): Secondary Teacher (Subject:

Elementary Teacher

)

Other (List:

)

I authorize you to provide the information regarding suitability for employment. APPLICANT SIGNATURE

SECTION B NOTE: Since the employment process cannot be completed until references are on file, the applicant and Human Resources Department would appreciate it if you would complete this reference form and return it to Human Resources Department of the SCHOOL BOARD OF BREVARD COUNTY as soon as possible. Our address is at the top of this form.

PHONE (

NAME OF REFERENCE

)

EXT

ADDRESS _______________________________________________________________________________ ZIP CODE ___________________________ NAME OF SCHOOL, BUSINESS OR AGENCY __________________________________________________ TITLE ______________________________ This reference covers the period from 19 to 19 . Title or position of reference during period of supervision or observation of the applicant: N Y Have you observed this applicant teach in a classroom situation or perform in a position similar to the one for which he/she is applying? N Would you employ this person in a position such as the one for which he/she is applying? Y N If this person is a former employee, would you rehire? Y Was this applicant teaching or working within his/her area of certification?

Y

N

Comments: This form will be shown to applicant or other member of the public only upon specific request, in compliance with Florida Statute 119.07, Public Records Laws.

SECTION C DIRECTIONS: Please consider this applicant in relationship to the following dimensions which have been identified as common characteristics of effective educators. Please indicate your rating by checking the appropriate box using the following scale. 5 = Extremely competent/professional 4 = Very competent/professional

3 = Competent/professional 2 = Less than competent/professional

1 = Much less than competent/professional 0 = No basis for judgment

CONTROL

Establishes and implements procedures to monitor and/or regulate processes, tasks, or activities. Takes action to monitor the results of assignments or projects.

PLANNING AND ORGANIZING

Establishes goals and objectives; designs and implements a plan of action to achieve those goals and objectives; designs and implements a method of evaluation to see if goals and objectives have been achieved.

DECISIVENESS/JUDGMENT

Exhibits ability to act and make decisions based on factual information and logical assumptions which are within the bounds of legal and ethical accepted practice.

SENSITIVITY

5

4

3

2

1

0

5

4

3

2

1

0

5

4

3

2

1

0

Acts in a manner that indicates a consideration for the feelings and needs of others.

5

4

3

2

1

0

INITIATIVE

Attempts to influence events to achieve goals; self-starting; originates action.

5

4

3

2

1

0

TOLERANCE FOR STRESS

Demonstrates stability of performance under pressure and/or opposition.

5

4

3

2

1

0

ADAPTABILITY/COOPERATION

Maintains effectiveness in varying learning or working environments during changes of task, responsibilities, or relationships. Relates well with others. Works through appropriate channels.

5

4

3

2

1

0

TECHNICAL/PROFESSIONAL PROFICIENCY

Exhibits knowledge and skill in regard to current research and development as it pertains to technical and professional practices. Applies professional procedures and principles, research and technology to achieve educational goals in most appropriate and effective way. Maintains appropriate records.

5

4

3

2

1

0

IMPACT/COMMUNICATION

Creates a good first impression, commanding attention and respect, showing an air of confidence, using appropriate oral, written, and body language.

5

4

3

2

1

0

LEADERSHIP

Utilizes appropriate interpersonal styles and methods in guiding students, parents, or peers toward task accomplishment.

5

4

3

2

1

0

JOB MOTIVATION

Exhibits a sense of personal satisfaction from the activities and responsibilities of the job as opposed to hours, pay, etc.

5

4

3

2

1

0

ATTENDANCE/PUNCTUALITY

Punctual and maintains good attendance.

5

4

3

2

1

0

SIGNATURE OF REFERENCE PER 9400 010 04/04

TITLE

A DRUG-FREE WORKPLACE

•

DATE

AN EQUAL OPPORTUNITY EMPLOYER

SCHOOL BOARD OF BREVARD COUNTY DEPARTMENT OF HUMAN RESOURCES SERVICES

Brevard Public Schools

2700 JUDGE FRAN JAMIESON WAY VIERA, FLORIDA 32940-6699

THE FUTURE OF FLORIDA'S SPACE COAST

NON-INSTRUCTIONAL APPLICANT REFERENCE FORM SUBSTITUTE APPLICANT REFERENCE FORM SECTION A - NOTE: Applicant completes SECTION A, Reference completes SECTIONS B and C APPLICANT'S NAME I have applied for a position with the SCHOOL BOARD OF BREVARD COUNTY in the following area(s): List positions for which you want to be considered I authorize you to provide the information regarding suitability for employment. SIGNATURE OF APPLICANT

SECTION B NOTE: Since the employment process cannot be completed until references are on file, the applicant and Human Resources Department would appreciate it if you would complete this reference form and return it to Human Resources Department of the SCHOOL BOARD OF BREVARD COUNTY as soon as possible. Our address is at the top of this form.

PHONE (

NAME OF REFERENCE

)

EXT

ADDRESS _______________________________________________________________________________ ZIP CODE ___________________________ NAME OF SCHOOL, BUSINESS OR AGENCY __________________________________________________ TITLE ______________________________ In what capacity have you known applicant?

Employee under my direction

Other

Applicant's position

Dates of employment: From (M/Y)

(M/Y)

Why did applicant leave your employ? Would you re-employ? (If NO, please

explain)

Comments:

This form will be shown to applicant or other member of the public only upon specific request, in compliance with Florida Statute 119.07, Public Records Laws.

SECTION C DIRECTIONS: Please consider this applicant in relationship to the following characteristics. Please indicate your rating by checking the appropriate box using the following scale. 5 = Excellent 4 = Above Average

3 = Average 2 = Below Average

1 = Unsatisfactory 0 = No basis for judgment

COMMUNICATION SKILLS

Able to communicate effectively with others.

ATTITUDE

Performs work in a positive and cooperative manner. Takes pride in quantity and quality of work.

ADAPTABILITY/COOPERATION

5

4

3

2

1

0

5

4

3

2

1

0

Adapts to varying work situations and responsibilities. Relates well with others.

5

4

3

2

1

0

DECISIVENESS/JUDGMENT

Acts and makes decisions based on factual information and 'common sense.'

5

4

3

2

1

0

QUALITY OF WORK

Work meets or exceeds expected standards.

5

4

3

2

1

0

ACCEPTS AND CARRIES OUT INSTRUCTIONS

Able to understand, accept, and carry out instructions.

5

4

3

2

1

0

INITIATIVE

Self-starting; originates action.

5

4

3

2

1

0

PLANNING/ORGANIZING

Identifies objectives; designs and implements a plan of action to achieve objectives in a timely manner.

5

4

3

2

1

0

DEPENDABILITY AND PERSEVERANCE

Acts responsibly and does what is necessary 'to get the job done.'

5

4

3

2

1

0

INTEREST IN WELFARE OF OTHERS

Recognizes and demonstrates interest in the needs and concerns of others at the worksite.

5

4

3

2

1

0

TOLERANCE FOR STRESS

Demonstrates stability of performance under pressure or opposition.

5

4

3

2

1

0

ATTENDANCE/PUNCTUALITY

On time and not often absent from work.

5

4

3

2

1

0

SIGNATURE OF REFERENCE PER 9400 010 04/04

TITLE

A DRUG-FREE WORKPLACE

•

DATE

AN EQUAL OPPORTUNITY EMPLOYER