<table style="width:100%;">
<colgroup>
<col style="width: 9%" />
<col style="width: 10%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 25%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="15">(All information given is protected by the Privacy
Act)</td>
</tr>
<tr class="even">
<td colspan="15">PROTÉGÉ INFORMATION FORM</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="14"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="14"></td>
</tr>
<tr class="odd">
<td>Name:</td>
<td colspan="14"></td>
</tr>
<tr class="even">
<td>Code:</td>
<td colspan="2"></td>
<td>Phone:</td>
<td colspan="3"></td>
<td>Email: </td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="2">JobTitle/Grade</td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="15">Describe your current job:</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="5">Number of years at GSFC</td>
<td></td>
<td colspan="5">Number of years in current position</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="13"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="13">What are your long-term career goals? (Include fields
of interest; occupations):</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="9">What are your objectives for this program? (Check all
applicable items)</td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="15"><p> Career development/exploration</p>
<p> Personal growth</p>
<p> Technical guidance</p>
<p> Leadership/management skills</p>
<p> Other</p></td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="15">Realistically, how much time can you invest in
developing your career?</td>
</tr>
<tr class="odd">
<td colspan="15">1 hour per week 2-3 hours per week 4 or more hours per
week</td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="15">Can you commit to attending the training and informal
sessions that are part of this</td>
</tr>
<tr class="odd">
<td colspan="10">program? (About 1/2 day per month) Yes No Not sure</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 12%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 14%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Name/Code :</td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="13"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>Do you know of someone whom you would like to
have as a mentor? If so, please write in name(s):</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="14"></td>
</tr>
<tr class="even">
<td colspan="14"></td>
</tr>
<tr class="odd">
<td colspan="14"><h3
id="if-case-the-individuals-you-named-above-is-are-not-available-or-if-you-dont-have">If
case the individual(s) you named above is (are) not available, or if you
don’t have</h3></td>
</tr>
<tr class="even">
<td colspan="14"><strong>someone specific in mind, please check the
preferences below (as many as apply):</strong></td>
</tr>
<tr class="odd">
<td colspan="14"></td>
</tr>
<tr class="even">
<td colspan="14">I prefer to be paired with someone who is</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12"> from the same Directorate</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"> from a different Directorate</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12"> Female Male</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"> African American</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12"> Native American</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"> European American</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12"> Asian American</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"> Latino/Hispanic American</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12"> A person with a disability</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"> Other</td>
</tr>
<tr class="odd">
<td colspan="14"><h3
id="do-you-require-any-special-accommodations-such-as-a-sign-language-or-oral">Do
you require any special accommodations such as a sign language or
oral</h3></td>
</tr>
<tr class="even">
<td colspan="14"><strong>interpreter, training materials in an alternate
format, etc.?</strong> Yes No</td>
</tr>
<tr class="odd">
<td colspan="14"></td>
</tr>
<tr class="even">
<td>Explain:</td>
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3">Signature/Date :</td>
<td colspan="8"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5">Supervisor’s Signature/Date:</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="14"><h2 id="section"></h2>
<h2 id="return-to-nichole-richmond-code-114">RETURN TO NICHOLE RICHMOND,
CODE 114</h2>
<p><strong>(Faxed copies acceptable – send to 6-1679) (Voice/TTY
6-1972)</strong></p></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>