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Staff Manual Guide 3113.3, Attachment B


Prepare an information sheet. The instructions in parentheses describe the information to be entered. Do not exceed one page.

(Actual size 8 1/2" x 11")


1. Name and organization of nominee:
(Use name exactly as it should appear on certificate. Include any doctoral degree used. Also indicate Miss, Ms., Mrs., Mr., as appropriate. For a group nomination, indicate the name of the group.)

2. Title, series, and grade of current position:
(Example - Consumer Safety Officer, GS-0696-12)

3. Brief statement of current duties:

4. Length of Government service:
Length of HHS service:
Length of FDA service:

5. Listing of previous honors and awards:
(If member of a group award, indicate name of award, name of group, and year received.) Example:
Quality Increase 1978
Commendable Service Award, Administrative Review Group, 1983

6. Brief summary of education:

7. Brief summary of work experience:

8. Proposed citation: (Twenty-five [25] words or less summarizing the service or achievement which serves as the basis for this nomination. Begin the citation with, "In recognition of..." --or-- "For ..." and do not include personal pronouns such as his, their, etc. When formulating the proposed citation, take special care to assure that it not only states what the award recognizes, but also that it is identifiable with the award criteria.)

9. Identification of criteria under which nominated:
(Example - Criteria B)

*NOTE: When a group is nominated, items 2 through 7 may be omitted, but a complete and accurate
alphabetical listing of the name and titles indicating Mr., Mrs., Ms., Miss, D.V.M.,
M.D., Ph.D., etc.; the organization for each person; and a brief statement beside each
name describing the role each individual played in the particular effort, is to be

Prepare a narrative justification (single-spaced). The instructions in parentheses describe the
information to be entered. Do not exceed three pages and do not attach written testimonials
or endorsements.

(Actual size 8 1/2" x 11")

Page ______


(Describe the employee's achievement or distinguished service, showing clearly the manner in which the nominee has met the award criteria. This statement should include sufficient detail to provide reviewing and advising boards with enough information to effectively evaluate the nominee's contribution. Some points to include, if applicable, are: impact of the achievement on Agency mission, function, or activity affected; level of effectiveness before and after improvement actions were taken; results obtained by the nominee's actions, including any quantifiable evidence of improvement; and, degree of ingenuity, innovation, or exceptional skill demonstrated by the nominee.)