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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


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Circular Exhibit 97-10-E


IHS RECOGNITION AND AWARDS PROGRAM NOMINATION AND APPROVAL FORM

Note:  For group awards, attach a list of group members, showing names, and award amount for each employee and individual CAN numbers.

  1. Employee's Last, First, and Middle Initial

  2. Organization

  3. Period Covered in Nominations (month, year) From:__________ To:__________

  4. Name of Award and Award Justification (use additional page as needed):  (Nominations for QSI's must show how the employee has met QSI criteria described in IHS Recognition and Awards Program Policy.  Other award nominations should be brief, no more than one page, and answer: 1) What was done? 2) Why is it exceptional and exemplary? 3) What is the reason the work deserves a monetary award? 4) What level of award is recommended?

    ____ Check here if requesting honor award for same achievement as monetary award nomination.

  5. Citation:  (Honor Awards Only) Summarize employee(s) contribution in 25 words or less.

  6. Number of Employees (if group)

  7. Total Award Amount or Hours

  8. Date of Last Within Grade Increase or QSI (for QSI Nomination Only)

  9. Initiating or Nominating Official Name/Title/Signature/Date:

  10. Peer Recognition Award Endorsement Only:
    __________________________________________________________________
    Signature
    ________________________________________
    Date
    __________________________________________________________________
    Signature
    ________________________________________
    Date

  11. Reviewing, Recommending, or Endorsing Official's Name/Title/Signature/Date (if required)

  12. Approving Official's Name/Title/Signature/Date

  13. Common Accounting Number (CAN)

  14. Fiscal Officer's Name/Title/Signature/Date

    TO BE COMPLETED BY SERVICING PERSONNEL OFFICE ONLY

  15. NOA

  16. EFFECTIVE DATE

  17. LEGAL AUTHORITY CODE:


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