Dodea Form 5011 – Fill Out and Use This PDF

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, 1155 Defense Pentagon, Washington, DC 20301-1155 (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 USC Sections 902, 903, and E.O. 9397.

PRINCIPAL PURPOSE: To obtain pertinent evaluation information about an applicant to assist management in making a hiring decision.

ROUTINE USE(S): Disclosure of the Social Security Number within the Department of Defense is authorized upon a demonstrated "need to know" to perform an official duty, including, but not limited to (1) DoD attorneys rendering advice and assistance; (2) DoD law enforcement or security activities concerning a law enforcement or security investigation. Routine disclosure of relevant and necessary information is authorized to agencies outside the DoD by DoD Privacy Act Systems Notices, which may be found at http://www.defenselink.mil/privacy/notices/osd/.

DISCLOSURE: Disclosure of the Social Security Number is voluntary. However, failure to disclose the number may delay or prevent the person completing Section II of this form and may delay the processing of your application for employment.

SECTION I

(Applicant Name and Social Security Number)

SECTION II

The above named individual is an applicant for employment with the Department of Defense Dependents Schools (DoDDS). The data that you provide will assist DoDDS 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.

USE ITEM 8 TO ELABORATE ON ANY OF THESE ITEMS.

1. PLEASE MARK (X) 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.DEPENDABILITY

l.CONDUCT/REPUTATION IN THE COMMUNITY

m.COMMITMENT TO CHILDREN

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

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

DoDEA FORM 5011, AUG 2008

PREVIOUS EDITION IS OBSOLETE.

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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?

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.)

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.

11. NAME AND ADDRESS OF YOUR SCHOOL

DoDEA FORM 5011 (BACK), AUG 2008