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Staff Manual Guide 3113.6, 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 attached.

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")


(Describe the employee's contribution or service and results achieved in sufficient detail to provide reviewing and advisory officials with enough information to make an effective evaluation. Include such factors as: (1) benefits resulting from the nominee's contributions (include number of persons affected and monetary benefits, if applicable); (2) the degree of ingenuity, innovation, or exceptional skill deomonstrated by the nominee; (3) the specific role of the nominee in accomplishing the achievement [if others are also involved]; (4) amount of time spent in activity, if applicable; (5) recognition nominee has received from professional, local government or communicty organizations [excerpts from letters from public and private officials, publications, etc., may be used to support statements of merit.])