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Applicant Information (PI/Faculty/equivalent)

 

 

Select type of request

 

 

 

Primary Traveler Information

 

 

 

 

 

 

 

 

 

 

 

Template Requestors Name

 

Please complete the following contact information.

 

 

 

 
mm/dd/yyyy

 
mm/dd/yyyy

 

 

 

 

 
mm/dd/yyyy

 

 

 

 

Requestor

 

 

BIOGRAPHICAL INFORMATION

*I would like more information on these topics

 

 

 

Requestor

 

 

 

 

*I would like more information on these topics

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Template Requestors Name
Requestor

 

 
mm/dd/yyyy

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy/Procedure Summary

 

Policy/Procedure Summary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy/Procedure Archive

 

 

 

P/P Request

 

 

 

 

 

P/P Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Your relationship to this individual

 

 

 

 

 

 

 

 

*Your relationship to this individual

 

*Your relationship to this individual

 

*Your relationship to this individual

 

*Your relationship to this individual

 

*Your relationship to this individual

 

*Your relationship to this individual

 

 

 

 

 

*Your relationship to this individual

 

 

 

 

 

 

*Your relationship to this individual

 
If you are not the contact person for this template, fill in the following fields.

 

 

 

 

 

 

 

 

 

 

 

 

Template Contact Name

 

 

Service Information
All related costs will be charged to the requesting department; however, no charges will be made to the company center number without prior written approval from the department.

 

 

 

 

 

If you are not the contact person for this template, fill in the following fields.

 

 

 

 

 

Explain how this employee has demonstrated HR BEST in Building Partnerships? (Please provide a detailed description.)
Service Information

 

 

 

Project Information

 

 

Current mailing address

 

 

 

 

Template Contact Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Job Description

 

 

 

 

 

 

 

 

 

*Job Description

 

*Job Description

 

 

 

Please provide the domain/directory the account(s) will be created in:

 

Please provide the domain/directory the account(s) will be created in:

 

*Preferred contact method:

 

 

*Do you have photos?

 

 

Please provide the domain/directory the account(s) will be created in:

 

 

 

 

 

 

 

*Photo Shoot

 

 

 

 

 

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New/Revised Template

 
NOTE: All External Kiosk Accounts will be created in Active Directory

 

 

 

 

Contact Information

 

 

 

 

 

 

 

 

 

 

 

*Who is the targeted population for this P/P?

 

 

 

 

 

 

NOTE: All Internal Kiosk Accounts will be created in Active Directory

 
Please provide the domain/directory the account(s) will be created in:

 

 

 

 

 

 

 

 

Please provide the domain/directory the account(s) will be created in:

 

(to upload multiple files, javascript must be enabled; attachments appear at end of form)

 

(to upload multiple files, javascript must be enabled; attachments appear at end of form)

 

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Entries must be received by Friday, February 14th 2014. One entry per employee.
Explain how this employee has demonstrated HR BEST in Engagement? (Please provide a detailed description.)

 

 

 

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Assessment
Assessment
Assessment
Assessment
Assessment
Assessment

 

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Assessment
Assessment

 

 

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Assessment

 

 

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If targeted population is Other

 

Template

 

Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Please type your question or comment in the box below.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.

 

 

Instructions if rating yourself: For each behavior statement, please rate the extent to which you agree with how the statement describes you.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.

 

Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Instructions if rating another individual: For each behavior statement, please rate the extent to which you agree with how the statement describes the individual for whom you have been asked to provide feedback.
Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

 

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

Be sure to provide a response for each statement in the questionnaire. There are no "right" or "wrong" answers. Your feedback will be most useful by answering the statements as accurately and honestly as possible.

*Will the template users need training?

 

 

 

 

 

 

 

 

 

Will this account be used in Direct Patient Care?

 

 

Behavior Demonstrated

 

 

 

 

Entries must be received by Thursday, May 31, 2012. One entry per employee.
Behavior Demonstrated
Behavior Demonstrated
Behavior Demonstrated
Behavior Demonstrated
Behavior Demonstrated
Behavior Demonstrated
Briefly identify the key points of the proposed P/P.

 

*Who is the targeted prpulation for this P/P/

 
Behavior Demonstrated
Will this account be used in Direct Patient Care?

 
Will this account be used in Direct Patient Care?
Behavior Demonstrated

 

 

 

*Request Type

 

 

 

Volunteers must be at least 21 years of age to volunteer in pediatrics.

 

 

 
mm/dd/yyyy
Volunteers younger than 18 years of age should apply to Teen Volunteers.

 

 

 

*Are you at least 18 years old?

 

 

 

Please indicate your availability for the following shifts.
Target Protein
Will this account be used in Direct Patient Care?

 

Afternoon Breakout Sessions
Thinking: Gather relevant information; break down problems; approach problems with curiosity and open-mindedness; make sound decisions.

 

 

 

 

Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.

 

 

*P/P is related to or initiated out of a:

 
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Will this account be used in Direct Patient Care?

 
Will this account be used in Direct Patient Care?

 
Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.
Basic Instructions for Creating Templates

 

 

Will this account be used in Direct Patient Care?

 

 
Weekday mornings (8:00 a.m. - 12:00 p.m. or 9:00 a.m. - 1:00 p.m.)
1. Create template as a Notepad document. Type your template headings in the order they should appear. Save your template.

 

Explain how this employee has demonstrated HR BEST in Service? (Please provide a detailed description.)
2. To ensure consistency: No multiple fonts, bolding or underline; Lines formatted for 79- 88 characters per line; Insert brackets [ ] to create check boxes.
3. Attach an example of your template in the field below.
Weekday afternoons (12:00-4:00 or 1:00-5:00 p.m.)
Permanent mailing address
All abbreviations must comply with the MDACC Do Not Use Abbreviations List, http://inside.mdanderson.org/departments/joint-commission/do-not-use.html

 

 

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Weekday evenings (5:00-8:30 p.m., 2-hour shift)
Saturday or Sunday (8:00 a.m. - 4:00 p.m., 4-hour shift, every other weekend)

 

P/P is related to or initiated out of a:

 

*Select all that apply

 
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Analytical Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Develops solutions that effectively address problems.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Develops solutions that effectively address problems.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Makes timely decisions in the face of uncertainty.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Generates well thought-out solutions to problems.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Focuses on important information without getting bogged down in unnecessary detail.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Sees underlying issues in complex situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Focuses on important information without getting bogged down in unnecessary detail.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1.Accurately identifies situations that require guidance or assistance from others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
1. Acts decisively to solve difficult problems.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Makes decisions based on sound logic and rationale.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Effectively troubleshoots problems that arise.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Generates well thought-out solutions to problems.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Makes decisions based on sound logic and rationale.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2.Effectively troubleshoots problems that arise.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Recognizes the impact that issues may have on his or her department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Takes all important issues into account when making decisions.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Recognizes the impact that issues may have on his or her department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
2. Applies thorough analysis to problems that warrant this level of attention.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Use a methodical step-by-step approach to break down complex problems or processes into their parts.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Makes decisions in the face of uncertainty.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3.Offers new ideas for ways to more effectively approach work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Does not overanalyze problems that do not warrant the attention.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Systematically evaluates a course of action and the potential consequences.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Effectively troubleshoots problems that arise.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Applies thorough analysis to problems that warrant this level of attention.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Makes decisions in the face of uncertainty.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
3. Identifies underlying issues and root causes of problems.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Compiles information from a variety of resources to obtain the most effective solution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Considers multiple sources of a problem before developing a solution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Use a methodical step-by-step approach to break down complex problems or processes into their parts.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Considers multiple sources of a problem before developing a solution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Does not overanalyze problems that do not warrant the attention.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Is comfortable making decisions and moving forward in uncertainty
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Systematically evaluates a course of action and the potential consequences.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Demonstrates respect for the processes by which decisions are made.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Considers multiple sources of a problem before developing a solution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Is comfortable making decisions and moving forward in uncertainty.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*6. Acts decisively to solve difficult problems.

 

*7. Exercises good judgment by making well-informed decisions.

 

*8. Demonstrates respect for the processes by which decisions are made.

 

 

 

 

Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)

 

 

 

For smaller groups to discuss specific questions. Limited to the first 50 registrants per session.

 

 

*Check all that apply

 

 

Policy / Procedure Document

 
Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)

 

 
Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)
Have you previously collaborated with a faculty member of statistical analyst in the Department of Bioinformatics and Computational Biology?

 

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*Has he/she been informed of your travel?

 
Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)

 

 

Breakout Session #1: 12:45 - 2:05 pm
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.

 

Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.
Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.
Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.
Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.
Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.
Strategic Thinking: Define strategic goals and issues clearly; apply broad knowledge and experience when addressing strategic issues; foresee obstacles and opportunities relating to change or improvement.
Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.
Strategic Thinking: Define strategic goals and issues clearly; apply broad knowledge and experience when addressing strategic issues; foresee obstacles and opportunities relating to change or improvement.

*Supervisor's Approval of Time Commitment

 

 

(to upload multiple files, javascript must be enabled; attachments appear at end of form)

 

Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)

 

Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)

 

Previous collaboration?

 

*How should P/P be prioritized?

 
Please provide the purpose for this account(s)?
(Please include all pertinent information. i.e. applications accessed, account-use environment, user/customer details, etc)

 

 
Explain how this employee has demonstrated HR BEST in Teamwork? (Please provide a detailed description.)
Please provide the following vendor information: 1)Vendor Company name, 2)Vendor Contact Name, 3)Vendor Contacte Phone Number

*Are you fulfilling a school requirement?

 

 

 

 

 

 

 
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Innovative Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Innovative Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Strategic Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Innovative Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Innovative Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Strategic Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Innovative Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Innovative Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4.Shows compassion when dealing with difficult or challenging customers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Encourages brainstorming and innovative ideas to promote change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Keeps the big picture in perspective.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Drives innovation and change within the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Challenges the Institution to constantly improve.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Drives innovation and change within the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Offers new ideas for ways to more effectively approach work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Offers new ideas for ways to more effectively approach work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
4. Serves as a resource to help others in generating new ideas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Serves as a resource to help others in generating new ideas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Develops plans that contain contingencies for change or uncertainty.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Challenges the Institution to constantly improve.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Creates innovative solutions that benefit the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Is open to new approaches and alternative practices that will help meet institutional goals and objectives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5. Supports innovation and change within the group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Is open to new approaches and alternative practices that will help meet institutional goals and objectives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
5.Goes above and beyond to exceed external and internal customer expectations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Applies lessons learned or best practices to improve future work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Supports opportunities for change and new ideas to improve individual, group or department performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6.Diligently follows through on customer concerns to the point of resolution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Approaches problems with curiosity and open-mindedness.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Creates innovative solutions that benefit the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
6. Creatively integrates different ideas and perspectives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Takes calculated risks to achieve organizational success.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Supports innovation and change within the group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Translates his or her vision into realistic business strategies.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Creatively integrates different ideas and perspectives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Creatively integrates different ideas and perspectives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Creates plans that balance long-term goals with immediate needs.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Translates his or her vision into realistic business strategies.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Applies lessons learned or best practices to improve future work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Approaches problems with curiosity and open-mindedness.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7.Is pleasant, courteous, and professional when dealing with internal or external customers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Develops plans that contain contingencies for change or uncertainty.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Creatively integrates different ideas and perspectives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Creates plans that balance long-term goals with immediate needs.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*15. Aligns resources to accomplish key organizational objectives.

 

NOTE: For questions regarding this form please contact Janice Freeman, Tracy Van Horne, LaTasha Burns, or Nicole Vaughn-Adams.

 

 
mm/dd/yyyy
Specify the Following Information for each account (max 10 accounts per form):
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date

 

Specify the Following Information for each account (max 10 accounts per form):
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date

 

Why are you interested in becoming a Diversity Council member?

 

 

Specify the Following Information for this account
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date

 

 

 

 

 

 

 
What type of volunteer position interests you?

 

Strategic Thinking: Define strategic goals and issues clearly; apply broad knowledge and experience when addressing strategic issues; foresee obstacles and opportunities relating to change or improvement.

 

Breakout Session #2: 2:05 - 3:25 pm
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Strategic Thinking: Define strategic goals and issues clearly; apply broad knowledge and experience when addressing strategic issues; foresee obstacles and opportunities relating to change or improvement.
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Specify the Following Information for each account (max 10 accounts per form):
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date
Specify the Following Information for each account (max 10 accounts per form):
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date
Are forms/documents tied to the policy that will be part of the medical record?
Specify the Following Information for each account (max 10 accounts per form):
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date

 

Specify the Following Information for each account (max 10 accounts per form):
1)Suggested Account Name
2) Account Owner/Employee ID
3) Computer Name(s) to Lock Down
4) Group Membership
5) Account Expiration Date

 

Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Describe exactly what you want us to provide. With respect to protein production you may require: cloning, mutagenesis protocol development, expression system development or improvement, large or small scale protein expression and/or purification.
Please provide any extra information necessary for this request.
Please provide any extra information necessary for this request.

 

*Requesting Continuing Medical Education (CME) credit

 

*Select all that apply

 

 

 

 

 
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Strategic Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Inspiring Trust
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Building Relationships
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Strategic Thinking
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Shows compassion when dealing with difficult or challenging customers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8.Adheres to the behavioral standards expected by the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Establishes open, candid, and trusting relationships.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Effectively coordinates resources to carry out projects or initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Supports and champions the initiatives of others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Builds alliances and partnerships across the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Relates well to people regardless of their title, personality, or background.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Manages aggressive yet realistic timeframes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
7. Shows compassion when dealing with difficult or challenging customers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Relates well to people regardless of their title, personality, or background.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Collaborates across boundaries, finding common ground with a wide range of stakeholders.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Works quickly to resolve conflicts when they arise.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Effectively coordinates resources to carry out projects or initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Goes above and beyond to exceed external and internal customer expectations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9.Is trusted by others in the work group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
8. Goes above and beyond to exceed external and internal customer expectations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Monitors progress of others and redirects efforts when goals are not being met.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17. Builds alliances and partnerships across the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*18. Seeks out relationships across the Institution that are mutually beneficial.

 
10. Translates business strategies into clear objectives and tactics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Works quickly to resolve conflicts when they arise.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10.Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Diligently follows through on customer concerns to the point of resolution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Diligently follows through on customer concerns to the point of resolution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Makes sure systems and processes are in place to complete the work efficiently.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
9. Promotes practices that are sensitive to the needs of a diverse workforce.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Leads an inclusive workplace that maximizes the talents of each person.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Is approachable and easy to talk with.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Promotes practices that are sensitive to the needs of a diverse workforce.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Remains calm when dealing with difficult or challenging customer situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Monitors progress of others and redirects efforts when goals are not being met.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Actively looking for ways to help customers by identifying and proposing appropriate solutions and services.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11.Holds self accountable for meeting commitments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Collaborates across boundaries, finding common ground with a wide range of stakeholders.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12.Accepts personal responsibility and ownership for the quality and timeliness of work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20. Cultivates an active network of relationships inside and outside the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Implements effective ways to monitor, measure, and evaluate customer satisfaction.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Translates business strategies into clear objectives and tactics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Is pleasant, courteous, and professional when dealing with internal or external customers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Demonstrates in-depth understanding and insight into customer concerns.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15. Fosters relationships by recognizing others' contribution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Promotes practices that are sensitive to the needs of a diverse workforce.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Promotes practices that are sensitive to the needs of a diverse workforce.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15. Builds an environment where customer satisfaction (internal and external) is always a priority.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13.Presents a professional image and attitude, refraining from gossip.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Leads an inclusive workplace that maximizes the talents of each person.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17. Fosters an inclusive environment where people are accepting and respectful of each other.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Promotes efforts to attract, develop, and retain a skilled and motivated workforce that is both diverse and inclusive.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Understands and respects cultural, religious, gender and racial differences.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Implements effective ways to monitor, measure, and evaluate customer satisfaction.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Remains calm when dealing with difficult or challenging customer situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*20. Demonstrates in-depth understanding and insight into customer concerns.

 
25. Understands the customer's current requirements and anticipates their future needs.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Goes above and beyond to exceed external and internal customer expectations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Builds an environment where customer satisfaction (internal and external) is always a priority.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Diligently follows through on customer concerns to the point of resolution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

 

 

Acknowledgement Statement:
I have completed this Account Request from and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.
Acknowledgement Statement:
I have completed this Account Request from and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.

 

 
What qualities, attributes or skills do you have that will contribute to your being a strong member of the Diversity Council?

*Part of policy?

 
You may request: consultation training, as well as structural and biophysical studies.

 

 

 

(to upload multiple files, javascript must be enabled; attachments appear at end of form)

 

 

 

Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Hazardous materials - Please state clearly any potential safety issues associated with the materials designated within this application.
Please provide any extra information necessary for this request.
Special Breakout Session #3: 3:40 - 5:10 pm
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Please provide any extra information necessary for this request.
Are other policies/procedures impacted by/relevant to this proposed policy/procedure?
Please provide any extra information necessary for this request.
Please provide any extra information necessary for this request.

 
Please provide any extra information necessary for this request.

 
I agree that if admitted to membership, I will undertake to be governed by the By-Laws of the Council.

 

 

 

Is there a particular type of volunteer position that interests you?
Team With Others
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Inspiring Trust
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Inspiring Trust
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Inspiring Trust
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Inspiring Trust
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Building Relationships
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Building Relationships
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Inspiring Trust
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Inspiring Trust
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14.Works well with others of a different background from him or herself.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Is trusted by others in the workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Speaks openly about tough issues facing the group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Adheres to the behavioral standards expected by the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
10. Adheres to the behavioral standards expected by the department.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15. Solicits the participation of peers and direct reports in initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Seeks out relationships across the institution that are mutually beneficial.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Takes the time to build credibility within the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Takes the time to build credibility within the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*17. Is straightforward and open in dealings with counterparts in the Institution.

 
12. Addresses conflict openly and constructively, focusing on issues rather than people.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
11. Is trusted by others in the work group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Speaks openly about tough issues facing the group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15. Is trusted by others in the work group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15.Demonstrates respect to others whether in their presence or absence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Seeks out relationships across the institution that are mutually beneficial.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Is straightforward and open in dealings with counterparts in the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Assumes responsibility for the outcome of his or her workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Maintains high ethical standards and integrity.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Maintains high ethical standards and integrity.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25. Is honest in his or her dealings with others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17. Can be approached easily.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16.Steps forward to assist group members and other co-workers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
13. Relates well to people regardless of their title, personality, or background.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
12. Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*13. Accepts personal responsibility and ownership for the quality and timeliness of work.

 
17. Holds self accountable for meeting commitments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15. Holds others accountable for achieving results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Addresses conflict openly and constructively, focusing on issues rather than people.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Shows consistency between words and actions.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Shows consistency between words and actions.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17.Works with group members and co-workers to resolve problems or conflicts.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Manages an inclusive workplace that maximizes the talents of each person.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Accepts personal responsibility and ownership for the quality and timeliness of work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Assumes responsibility for the outcome of his or her workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
14. Presents a professional image and attitude, refraining from gossip.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
15. Prioritizes activities and implements practices to ensure customer needs are met.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Relates well to people regardless of their title, personality, or background.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*20. Promotes practices that are sensitive to the needs of a diverse workforce.

 
28. Holds self accountable for meeting commitments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Fosters an environment that is focused on delivering quality customer service.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Presents a professional image and attitude, refraining from gossip.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Manages an inclusive workplace that maximizes the talents of each person.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Presents a professional image and attitude, refraining from gossip.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20. Starts and completes work without close supervision.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Holds others accountable for achieving results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Understands and respects cultural, religious, gender and racial differences.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*23. Prioritizes activities and implements practices to ensure customer needs are met.

 

*24. Fosters an environment that is focused on delivering quality customer service.

 

*25. Makes the effort to understand the nature of customer issues before taking action.

 

 

 

*Impacted or Relevant?

 

 

*Select to indicate agreement

 

 

 

 

 
Contact Information at Destination

 

 

*Gender

 
Technical/Functional Expertise: Demonstrate technical proficiency required to do the job; possess expertise knowledge in the profession.
Acknowledgement Statement:
I have completed this Account Request from and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.
Preliminary materials and methods to be provided by requestor. What will you provide - clones, plasmids, antibodies, reagents, etc? Do you have an established or preferred protocol that we should use?
Acknowledgement Statement:
I have completed this Account Request from and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.
Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.
Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.
Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.
Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.
Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.
Business Acumen: Understand the impact of the job within the Institution; use cross-functional knowledge to understand interdepartmental connections.
Acknowledgement Statement:
I have completed this Account Request from and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.
If yes to the previous question, list the P/P titles(s), policy numbers(s), and make necessary revisions.
Acknowledgement Statement:
I have completed this Account Request form and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.
Acknowledgement Statement:
I have completed this Account Request from and acknowledge its accuracy. I have reviewed & agree to uphold the requirements outlined in the Information Security Operations Manual for the account(s) outlined in this form.

 

 

Thank you for taking the time to complete this form.
Technical/Functional Expertise
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Team With Others
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Business Acumen
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Business Acumen
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Inspiring Trust
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Team With Others
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Inspiring Trust
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Team With Others
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Team With Others
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15. Works well with others of a different background from him or herself.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Controls costs while driving revenue generation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Knows when to jump in to assist employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Speaks openly about tough issues facing the group.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17. Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20. Allocates resources (people, time and money) to achieve optimal results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18.Holds the skills and knowledge to be effective in his or her role.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Works well with others of a different background from him or herself.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Knows when to jump in to assist employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
16. Demonstrates respect to others whether in their presence or absence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Demonstrates respect to others whether in their presence or absence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Efficiently coordinates group efforts to meet deadlines and outcomes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Assumes responsibility for the outcome of his or her workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17. Efficiently coordinates group efforts to meet deadlines and outcomes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Acts according to his or her stated values.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Ensures financial resources are directed toward strategic initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19.Demonstrates technical proficiency needed to perform the job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Allocates resources (people, time and money) to achieve optimal results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Draws accurate conclusions from financial and other quantitative information.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Acknowledges and celebrates group accomplishments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Creates a work environment that encourages high standards.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20.Keeps skills up to the level needed to successfully complete tasks.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Steps forward to assist group members and other co-workers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Acts a role model by consistently displaying a strong work ethic and professional attitude.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Uses cross-organizational understanding to facilitate the needs and objectives of the organization.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
17. Steps forward to assist group members and other co-workers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Acknowledges and celebrates group accomplishments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Treat others' concerns and issues with sensitivity and confidentiality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Works with group members and co-workers to resolve problems or conflicts.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
18. Works with group members and co-workers to resolve problems or conflicts.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Identifies and uses key financial indicators necessary to measure business performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Understands how to execute the organization's business strategy to deliver the desired results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25. Shares information and expertise with other employees to enable the successful completion of the group's goals.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Assumes responsibility for the outcome of his or her workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Makes prudent decisions regarding significant expenditures.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Understands the major functions of the different areas of the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Holds self accountable for meeting commitments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25. Remains engaged in what's going on in all areas of the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
36. Ensures financial resources are directed toward strategic initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*37. Draws accurate conclusions from financial and other quantitative information.

 
32. Acts a role model by consistently displaying a strong work ethic and professional attitude.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Identifies and uses key financial indicators necessary to measure business performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*39. Makes prudent decisions regarding significant expenditures.

 

*40. Remains engaged in what's going on in all areas of the Institution.

 
Travel Safety

 

 

 

 
If previous protein production was attempted briefly explain what steps were tried and what was the outcome. Note: Please do not provide any reagents that are irreplaceable.

 

 

 

Communication: Express ideas clearly and concisely; listen to feedback and input carefully; acknowledge differing perspectives in a group.
Please describe all precautionary measures taken or provided by organizers to ensure your safety and health while traveling.

 

Technical/Functional Expertise: Demonstrate technical proficiency required to do the job; possess up-to-date expertise knowledge in the profession; provide technical expertise to others.
Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.
Implementation Plans
Technical/Functional Expertise: Demonstrate technical proficiency required to do the job; possess up-to-date expertise knowledge in the profession; provide technical expertise to others.
Global Perspective: Understand the position of the Institution within the industry; anticipate the impact of technological, social, and economic trends on the Institution.
Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.
Team With Others: Encourage collaboration and input from all team members; value the contributions of all members; balance individual and team goals.
Global Perspective: Understand the position of the institution within the industry; anticipate the impact of technological, social, and economic trends on the institution.
Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.

*Have you ever been convicted of a felony?

 
Business Acumen
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Team With Others
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Communication
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Team With Others
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Business Acumen
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Technical/Functional Expertise
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Technical/Functional Expertise
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Global Perspective
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Global Perspective
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Holds the skills and knowledge to be effective in his or her role.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21.Listens attentively to information or directions provided by others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20. Identifies and removes barriers to effective teamwork.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Identifies and removes barriers to effective teamwork.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Anticipates trends and future developments in the healthcare environment.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Anticipates trends and future developments in the healthcare environment.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Holds the skills and knowledge to be effective in his or her role.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
19. Possesses technical and industry knowledge needed to support the institution's best interests.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Possesses technical and industry knowledge needed to support the institution's best interests.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Determines how best to be positioned to achieve a competitive business advantage in a global economy.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20. Demonstrates technical proficiency required to do the job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22.Keeps others informed about his or her work activities.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
20. Understands the general roles and responsibilities of other functional areas in the institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Acknowledges and celebrates group accomplishments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
42. Determines how best to be positioned to achieve a competitive business advantage in a global economy.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Understands the general roles and responsibilities of other functional areas in the institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Establishes a climate where all employees can contribute to their full potential.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Demonstrates technical proficiency required to do the job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Acknowledges and celebrates group accomplishments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Demonstrates an awareness of what impacts the organization and its success.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23.Communicates clearly with others whether in writing or speaking.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Develops strategies to achieve and sustain competitive advantage.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Involves others in shaping plans and decisions that affect them.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
43. Keeps abreast of global trends (e.g., technological, competitive, economic) that could impact the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
36. Demonstrates an awareness of what impacts the organization and its success.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
21. Quickly masters new technical knowledge necessary to do the job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Has up-to-date knowledge in the profession and industry.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
36. Involves others in shaping plans and decisions that affect them.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Quickly masters new technical knowledge necessary to do the job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Develops strategies to achieve and sustain competitive advantage.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*Reason for request. How will you use the results?

 
Communication / Education Plan

 

Include specific information related to the local threat level, and the measures that will be in place to assure your safety.
Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

 

 

Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.
How will the P/P be communicated to the affected constituents? [For example, Clinical Managers Forum (if house-wide P/P), Nursing Leadership or Departmental staff meeting, electronic communications, etc.]
Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.
Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.
Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.
Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.
Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
ACADEMIC HISTORY
Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Coach and Develop
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Coach and Develop
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Business Acumen
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Coach and Develop
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Business Acumen
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Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Coach and Develop
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Demonstrates interest in developing the careers of his or her employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
45. Demonstrates interest in developing the careers of his or her employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Listens to suggestions and input from others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Possesses technical and industry knowledge needed to support the institution's best interests.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24.Willingly accepts changes that occur in the group or institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Identifies performance issues and takes quick, corrective action to address performance gaps.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
22. Listens to suggestions and input from others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
37. Provides opportunities for development to employees on a regular basis.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
37. Possesses technical and industry knowledge needed to support the institution's best interests.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Exerts the personal effort to understand the other business areas of the institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
46. Provides feedback to employees to let them know their efforts are appreciated.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Provides feedback to employees to let them know their efforts are appreciated.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Understands the general roles and responsibilities of other functional areas in the institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Identifies performance issues and takes quick, corrective action to address performance gaps.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Effectively balances being detailed with being concise in his or her communication.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Effectively balances being detailed with being concise in his or her communication.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
23. Gives specific and constructive feedback to enhance others' development.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25.Remains open to learning new methods or procedures resulting from an institutional or a departmental change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25. Ensures financial resources are directed toward strategic initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Willingly shares expertise and experience with others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
24. Communicates clearly with others whether in writing or speaking.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Communicates clearly with others whether in writing or speaking.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
39. Gives specific and constructive feedback to enhance others' development.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
39. Exerts the personal effort to understand the other business areas of the institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Identifies required capabilities and skill gaps within own organizational area.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
47. Identifies required capabilities and skill gaps within own organizational area.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26.Remains calm under pressure or heavy workload.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Understands the meaning and implications of key financial indicators.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
40. Willingly shares expertise and experience with others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Promotes sharing of expertise and a free flow of learning across the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27.Responds with flexibility to shifting priorities and rapid change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
40. Demonstrates an awareness of what impacts the organization and its success.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
48. Promotes sharing of expertise and a free flow of learning across the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28.Deals constructively with own failures and mistakes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
49. Creates a climate in which mistakes are viewed as opportunities for learning.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Remains aware of activities impacting budget.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*42. Ensures financial resources are directed toward strategic initiatives.

 

*43. Understands the meaning and implications of key financial indicators.

 

 

Emergency Contact Information

*CBSF Support

 
Personal Contact

 

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.
Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

 

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.
Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.
Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

 
mm/dd/yyyy
Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.
Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

 

Self-Adaptability
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Influencing Others
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Self-Adaptability
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Influencing Others
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Influencing Others
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Self Motivation
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Coach and Develop
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Influencing Others
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Coach and Develop
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29.Demonstrates a strong sense of urgency about getting the work done.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Willingly accepts changes that occur in the group or institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Provides opportunities for development to employees on a regular basis.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25. Willingly accepts changes that occur in the group or institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Assesses employees' unique development needs.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Moves group toward decisions even when initial disagreement exists.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
50. Creates a climate that fosters personal investment and excellence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Leads by example, showing a willingness to extend him or herself to achieve results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
25. Moves group toward decisions even when initial disagreement exists.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Remains open to learning new methods or procedures resulting from an institutional or a departmental change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
42. Knows who to involve and when.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30.Starts and completes work without close supervision.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Knows who to involve and when.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
26. Remains calm under pressure or heavy workload.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
51. Leads by example, showing a willingness to extend him or herself to achieve results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Develops employees through challenging assignments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
45. Assesses employees' unique development needs.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Pushes the Institution to adopt new ideas and initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Gains cooperation from others to accomplish goals by providing convincing information.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Gives specific and constructive feedback to enhance others' development.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
43. Gains cooperation from others to accomplish goals by providing convincing information.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Approaches each problem situation with a clear understanding of institutional and political reality.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31.Readily puts in extra time and effort.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Works effectively in ambiguous situations and demonstrates flexibility when needed.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
52. Helps others to see the value of what they are doing.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
27. Responds with flexibility to shifting priorities and rapid change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
46. Develops employees through challenging assignments.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*47. Gives specific and constructive feedback to enhance others' development.

 
36. Gains commitment from others before implementing changes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Deals constructively with own failures and mistakes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
36. Remains calm under pressure or heavy workload.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
53. Pushes the Institution to adopt new ideas and initiatives.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*54. Understands the social and political dynamics within the Institution.

 
37. Responds with flexibility to shifting priorities and rapid change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
48. Set goals to aid employees in continuously raising the bar on performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Deals constructively with own failures and mistakes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
55. Navigates the political networks present within the Institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*56. Approaches each problem situation with a clear understanding of institutional and political reality.

 

*57. Gains commitment from others before implementing changes.

 
Monitoring / Auditing Plan

 

 

Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.
Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.
Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

 

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.
Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.
Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.
Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.
Is monitoring / auditing of the P/P needed for compliance?
Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.
Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

 

Providing Direction
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Not At All
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Influencing Others
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Providing Direction
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self Motivation
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self Motivation
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Providing Direction
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Providing Direction
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Gains commitment from others in support of initiatives or ideas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32.Displays a willingness to learn new things.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Takes into account employee's concerns during a change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
39. Overcomes obstacles to achieve results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Overcomes obstacles to achieve results.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
28. Helps others adapt to changing environments and accept new situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
49. Gains commitment from others in support of initiatives or ideas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
58. Actively champions initiatives to ensure successful implementation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
37. Actively champions initiatives to ensure successful implementation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
40. Demonstrates a strong sense of urgency about getting the work done.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
59. Assumes personal responsibility to see that change is adopted and effectively implemented.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Demonstrates a strong sense of urgency about getting the work done.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
45. Helps others adapt to changing environments and accept new situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
29. Delegates important tasks, not just tasks that he or she does not want to do.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Moves the group toward decisions even when initial disagreement exists.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Assumes personal responsibility to see that change is adopted and effectively implemented.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33.Solicits developmental feedback from more experienced peers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
50. Moves the group toward decisions even when initial disagreement exists.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
39. Provides direction that is consistent with organizational goals.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
60. Balances change with continuity to continually improve.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Strives to meet or exceed performance goals or standards.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
46. Delegates important tasks, not just tasks that he or she does not want to do.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34.Takes it upon him or herself to increase knowledge and skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
51. Knows who to involve and when.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Knows who to involve and when.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Sets high personal standards of performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
30. Provides direction to employees on a regular and consistent basis.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
52. Anticipates the positions and reactions of others accurately.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
61. Creates a work environment where employees respond with focus toward change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
31. Helps employees gain clarity about expectations for their role and job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Readily puts in extra time and effort.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Provides compelling reasons for his or her perspective on an issue.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
47. Provides direction to employees on a regular and consistent basis.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
42. Sets high personal standards of performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
40. Provides employees the support and autonomy to carry out their work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
53. Provides compelling reasons for his or her perspective on an issue.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Creates a clear, inspiring vision of the desired future state of the organization.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
48. Helps employees gain clarity about expectations for their role and job.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
43. Readily puts in extra time and effort.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
62. Provides direction that is consistent with organizational goals.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*63. Provides employees the support and autonomy to carry out their work.

 

*64. Does not become overly involved in operations that do not warrant this level of attention.

 

*65. Creates a clear, inspiring vision of the desired future state of the organization.

 

 

*Monitoring / Auditing

 

 

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
Secondary Contact
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.
If yes to the previous question, complete the following.
Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

 

 

Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Providing Direction
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Providing Direction
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
32. Encourages open discussions around important topics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Displays a willingness to learn new things.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
66. Communicates the vision of his or her workgroup to employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
54. Considers the concerns voiced by others when implementing a change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
42. Encourages open discussion around important topics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Displays a willingness to learn new things.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Helps others adapt to changing environments and accept new situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
49. Encourages open discussions around important topics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*50. Keeps others informed.

 
67. Encourages open discussion around important topics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
55. Anticipates and effectively manages others' resistance to change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Takes it upon him or herself to increase knowledge and skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
33. Listens attentively to people's ideas and concerns.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
43. Consistently shares information about important activities with employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
45. Solicits developmental feedback from more experienced peers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Sets appropriate goals and objectives for the workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Recognizes own strengths and weaknesses.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
46. Takes it upon him or herself to increase knowledge and skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
36. Sensibly delegates and assigns work to employees according to their capabilities.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
51. Listens attentively to people's ideas and concerns.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
34. Communicates information in a well-organized and concise manner.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
56. Helps others adapt to changing environments and accept new situations.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
68. Tailors communication to the audience.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Encourages others to express their views, even contrary ones.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
47. Recognizes own strengths and weaknesses.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
57. Sets appropriate goals and objectives for the workgroup.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
69. Consistently shares information about important activities with employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
52. Communicates information in a well-organized and concise manner.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
37. Clearly communicates deadlines and expectations for work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
58. Sensibly delegates and assigns work to employees according to their capabilities.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
70. Encourages others to express their views, even contrary ones.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Provides employees the support and autonomy to carry out their work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
59. Clearly communicates deadlines and expectations for work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*60. Provides employees the support and autonomy to carry out their work.

 

*61. Establishes high standards of performance for employees.

 

 

 

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

 

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
What will be monitored?
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.
Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.

 

Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Communication
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
39. Encourages open discussions around important topics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
45. Adapts his or her leadership style to fit the employee and situation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
53. Willingly accepts changes that occur in the group or institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
35. Willingly accepts changes that occur in the group or institution.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
62. Uses effective listening skills to gain clarification from others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
71. Adapts his or her leadership style to fit the employee and situation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
46. Encourages productivity from his or her employees by understanding what motivates each one to do their best.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
36. Works constructively under stress and pressure.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
63. Creates an environment that supports the open exchange of ideas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
40. Consistently shares information about important activities with employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
54. Works constructively under stress and pressure.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
72. Provides support to direct reports that matches the needs of the situation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Listens attentively to concerns expressed by others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
64. Encourages open discussions around important topics.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
37. Responds with flexibility to shifting priorities and rapid change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
55. Responds with flexibility to shifting priorities and rapid change.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
73. Encourages productivity from his or her employees by understanding what motivates each one to do their best.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
47. Commands authority when the situation calls for it.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
65. Consistently shares information about important activities with employees.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
74. Commands authority when the situation calls for it.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
66. Listens attentively to concerns expressed by others.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

 

 

 

 

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.
Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.
Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.
Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.
Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.
Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.

 

If you have had a significant (1 semester or greater) interruption in your college studies, please provide details.
Self-Confidence
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Confidence
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Confidence
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Confidence
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
42. Regularly exerts the effort to develop new or improved skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
67. Solicits developmental feedback from more experienced peers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
56. Handles mistakes with poise and confidence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
75. Confronts problems directly in low-performance areas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
48. Confronts problems directly in low-performance areas.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
38. Handles mistakes with poise and confidence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
57. Tackles problems head-on and works to resolve them.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
49. Projects self-assurance and unshakable confidence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
68. Regularly exerts the effort to develop new or improved skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
39. Tackles problems head-on and works to resolve them.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
43. Understands own and others' learning needs and preferences.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
76. Projects self-assurance and unshakable confidence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
50. Acknowledges own limitations and leverages others' strengths to compensate for them.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
77. Acknowledges own limitations and leverages others' strengths to compensate for them.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
69. Understands own and others' learning needs and preferences.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
78. Seeks feedback to enhance performance.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
70. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
You are encouraged to register through the US Embassy web site.
When will the monitoring be done?

 

REFERENCES
Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.
Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.
(See U.S. U.S. State Department Registration web site).

 

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.
Two references are required in support of your application. List names, credentials, physical addresses and email addresses for individuals who will provide references on your behalf.
Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self Motivation
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Adaptability
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self Motivation
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
58. Establishes clear, challenging goals with measurable outcomes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
45. Adjusts his or her leadership style to the situation or person.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
71. Provides support to direct reports that matches the needs of the situation.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
40. Establishes clear, challenging goals with measurable outcomes.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
72. Encourages individual initiative in carrying out work.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
46. Encourages productivity from his or her employees by understanding what motivates each one to do their best.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
59. Demonstrates a strong sense of urgency about getting the work done.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
41. Demonstrates a strong sense of urgency about getting the work done.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
60. Strives to meet or exceed performance goals or standards.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
73. Adjusts his or her leadership style to the situation or person.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
42. Strives to meet or exceed performance goals or standards.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
47. Works constructively under stress and pressure.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*48. Responds resourcefully to demands and challenges.

 
74. Encourages productivity from his or her employees by understanding what motivates each one to do their best.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*75. Works constructively under stress and pressure.

 

*76. Responds resourcefully to demands and challenges.

 
How will the monitoring be accomplished?
By registering, U.S. citizens make it easier for the Embassy to contact them in case of emergency.

 

 

Note: if you are not a U.S. citizen, you are encouraged to look into registering with the Embassy of your citizenship.
Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.
Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.
Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.
Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.
NOTE: Within 3 months of the P/P's implementation, you will be asked to produce reports regarding the P/P's implementation efforts, which will be sent to the Policy Governor, so keep track of your monitoring and auditing with reports.

 

Self-Confidence
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Develop Oneself
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
Self-Confidence
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*49. Handles mistakes with poise and confidence.

 
43. Recognizes own strengths and weaknesses.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
61. Solicits developmental feedback from more experienced peers.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
77. Handles mistakes with poise and confidence.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
62. Recognizes own strengths and weaknesses.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
78. Makes positive changes to behavior in response to feedback.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
50. Makes positive changes to behavior in response to feedback.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate
44. Regularly exerts the effort to develop new or improved skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*45. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.

 
63. Regularly exerts the effort to develop new or improved skills.
Not At All Some Extent Great Extent Very Great Extent Cannot Rate

*64. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.

 
Acknowledgements
Policy/Procedure Document

 

Registration with the International SOS is required either by booking travel with MD Anderson contracted agency, Corporate Travel Planners, or by manually enrolling in International SOS prior to my departure.
Provide information of 2 people who may be contacted for questions regarding the P/P.
(To learn more about the services available to University of Texas employees, visit the International SOS and enter the membership number for UT System - 11BSGC000037.)

 

*International SOS

 

 

 

*Travel Safety guidelines

 

 

 

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HOUSING

 

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A limited number of spots in UTHSC-Houston student housing is available and affordable. The cost of this housing will be at the student's expense.

 

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*Will you require housing?

 

 

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As described in the CPRIT Summer Undergraduate Research Program Announcement, a stipend of $5000 will be provided for the 10-week program.

 

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CAREER PLANS

*Indicate if you plan to pursue post-graduate education.

 

 


NOTE: For questions regarding this form please contact Janice Freeman, Tracy Van Horne, LaTasha Burns, or Nicole Vaughn-Adams.

 

 

RESEARCH
If selected, you will perform research sponsored by CPRIT within the laboratory of an assigned faculty mentor at the University of Texas, MD Anderson Cancer Center.
In order to match your interests with available mentors, please attach a description of any past research experience, specific areas of research interest and particular situations that led to this interest.
The format for this description is:
Double-spaced
Font: Arial or Helvetica
Size: 12pt or greater
Length: 500 words or less
SUPPORTING DOCUMENTATION
This application must be accompanied by
Current college transcript (may be attached or sent separately)
Two letters of reference (may be attached or sent separately)
Description of Research Experience and Interest (attach below)

 

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SUBMIT APPLICATION
All materials must be received by December 31, 2011. It is the applicant's responsibility to ensure that the application and supporting documentation (letters, transcripts) is submitted on time.
Letters of reference and current college transcript may be submitted via email to: gradschool@mdanderson.org
Please include your name in the subject line of emails submitted to gradschool@mdanderson.org. Late applications or applications that do not follow the guidelines will not be considered.
I understand that all application material submitted to The University of Texas M. D. Anderson Cancer Center becomes the property of the Institution.
I understand this information will be used to determine my eligibility for appointment and training.
I agree to notify the proper M. D. Anderson officials of any changes in the information provided.
I certify that the information in this application is accurate and complete to the best of my knowledge.
I acknowledge that the submission of any false information is grounds for the rejection of my application, withdrawal of acceptance offer, appointment revocation, or appropriate disciplinary action after appointment.