NRC FORM 212

(04-01-2024)

QUALIFICATIONS INVESTIGATION 

PROFESSIONAL, TECHNICAL, AND 

ADMINISTRATIVE POSITIONS

U.S. NUCLEAR REGULATORY COMMISSION 

NRC MD 10.1

APPROVED BY OMB: NO. 3150-0033 EXPIRES: 04/30/2024

Estimated burden per response to comply with this mandatory information collection request: 

30 minutes. This information is used to determine the qualifications and suitability of external 

applicants for employment. Send comments regarding burden estimate to the FOIA, Library, 

and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, 

Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and the OMB 

reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0033), Attn: Desk 

Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 

20503. The NRC may not conduct or sponsor, and a person is not required to respond to, a 

collection of information unless the document requesting or requiring the collection displays a 

currently valid OMB control number. 

NRC FORM 212 (04-01-2024) Page 1 of 2

Start Date (MM/DD/YYYY)

 Above Average

Name of Applicant:

The applicant named below has applied for a position in the NRC. Please rate the applicant in the items listed below with respect to the period 

of time you either supervised or were acquainted with the applicant. Include any comments you may feel are relevant. Please return the 

completed form to the Human Resources Specialist listed in the "FROM" block by the return date indicated, sealed in the enclosed envelope 

and marked For Addressee Only.

Position for which applied: From:

To: (Name and title of supervisor or reference Human Resources Specialist 

Office of the Chief Human Capital Officer 

U. S. Nuclear Regulatory Commission 

Washington, DC 20555

Confirmed Dates of Employment

End Date (MM/DD/YYYY)

Applicant's position with your company:

TECHNICAL AREA:

How well did the applicant know the work?

 Average Below Average

 Above Average

How well did the applicant perform?

 Average Below Average

 Above Average Average Below Average

How well did the applicant manage the workload?

What were his/her strengths?

What were his/her weaknesses?
NRC FORM 212

(04-01-2024)

U.S. NUCLEAR REGULATORY COMMISSION 

NRC MD 10.1 QUALIFICATIONS INVESTIGATION PROFESSIONAL, TECHNICAL, AND 

ADMINISTRATIVE POSITIONS (Continued)

How would you describe the applicant's relationship with:

CHARACTERISTICS:

REQUIRED QUESTIONS:

1. Have you any reason to question this applicant's trustworthiness or loyalty to the U. S.?

2. Do you know of any personal habits or characteristics that would make this applicant unsuitable for 

 employment by the U. S. Government?

3. Is this applicant eligible for re-hire in your organization?

Relationship to Applicant:

NOTE: Consistent with the Privacy Act of 1974, this evaluation may be revealed to the applicant upon his or her request. 

 However, if you request, your identity and other identifying information will be kept confidential.

 Above Average Average Below Average

Was the applicant dependable?

 Above Average Average Below Average

How did the applicant work in stressful situation?

Co-workers?

Supervisors?

Higher Officials?

 Yes No

 Yes No

 Yes No

 Supervisor Co-worker Professional Other (Specify):

 My Identity May be Revealed I Request My Identity be kept Confidential

Typed Name and/or Title of Interviewer

Signature of Interviewer

Additional Comments

NRC FORM 212 (04-01-2024) Page 2 of 2