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Please
complete the following questionnaire, provide examples
of excellence for Sections 1- 4. Each section will receive equal consideration. Supervisor
acknowledgement is required for candidate’s
final consideration and will be obtained by the
committee. You may use a separate sheet of paper
to provide the answers, if necessary.
Date submitted: ________________________________________________________________
Name of person nominated: ______________________________________________________
Department: __________________________________________________________________
Immediate Supervisor: ___________________________________________________________
Section 1 - Caring: Describe
how the nominee illustrates that he or she cares
for others, for co-workers, for clients and for the
UT Dental Branch or UT Health Science Center at Houston
community. An example of caring might include
the employee’s dedication to helping someone
in need.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Section 2 - Commitment: By
working together we merit the trust of our colleagues
and those we serve. How does this person exemplify
the Dental Branch’s commitment to making a
difference in the work place?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Section 3 - Integrity: How
does the nominee earn their co-workers’ respect?
How do they show that they have high principles for
themselves and others by “doing the right thing?”
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Section 4 - Knowledge: Describe
how the nominee follows through, instills confidence
in co-workers and clients and that they are competent
in their position and attempt to stay current in
their profession.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Name of person(s) completing form: _______________________________________________
Signature: ____________________________________________________________________
Contact Information: ____________________________________________________________
Please send this completed form to:
Cecilia Garza, Chair of
Selection Committee
DB 3.094H
(713) 500-4405
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