UNIVERSITY OF CALIFORNIA, LOS ANGELES

1996-97 INCENTIVE AWARD NOMINATION FORM

Part One: To be completed by the individual making a nomination of an eligible employee. Nominations may be made by an employee's immediate supervisor, or another supervisor/manager/director in the employee's department, or a customer of the employee or the employee's department (e.g. faculty, staff, students, patients or vendors who the employee provides a service or product to on a regular basis).

 Justification: (Please state the nominee's qualifications for this award, including as much specific information as possible concerning demonstrated actions which resulted in improved department performance or enhanced its operations, or increased customer/client satisfaction, or evidence or extraordinary creativity, innovation, or impact on the department or campus community, or a special one-time contribution of measurable significance to your department's mission or strategic plan.)

 Part Two: To be completed by department administrators. If approved, forward to the appropriate Dean, Provost or Vice Chancellor for final review and approval.

1. Rating on most recent performance evaluation: ___________________________________________

2. Nominee's Annual Pay Rate: $_________________________________________________________

3. Amount of award (up to 10% of annual pay rate): $________________% of Award______________

4. Is nominee in a contract appointment? q yes q no

5. Nominee's Date of Hire: _____________________________________________________________

6. Comments of Supervisor (if different from nominator): _____________________________________

7. Comments of Department Head/Supervisor

8. Account/Fund Number from which employee is paid: ___________________________________

9. Priority Number (if submitting more than one nomination): ________________________________

1. Award denied: q

Return Incentive Award Nomination Form to Department Head.

2. Award approved: q

(Page 2 of 2)