ELP-Nominator-Form_2015 FORM
2015
CONTACT INFORMATION
________________________________________________________________________________________________________________________________________________
Name of Applicant
Name of Nominator
Title
Nominator’s Address
City
State
Zip Code
Telephone
Fax
E-mail
TO THE NOMINATOR:
The Emerging Leader Program (ELP) is aimed at mid-career high potential laboratory professionals who want to perform
their work at a higher level of effectiveness. The program is a year in duration. It includes various skill development
workshops and a leadership project that participants develop and execute. The project is a living laboratory for
leadership concepts and skills explored in the program. An alumni-based peer coaching program supports each
participant during the ELP experience.
The applicant named above is a candidate for the Emerging Leader Program co-sponsored by the Association of Public
Health Laboratories (APHL), through a Cooperative Agreement with the Centers for Disease Control and Prevention
(CDC). We appreciate your honest and objective evaluation of the applicant. Your careful consideration of the applicant’s
ability to benefit from this program is greatly appreciated. Thank you.
Please answer the questions on the following page. Note if you need more space, the form will automatically expand.
Please note that this form must be completed by the applicant’s laboratory director.
ELP-Nominator-Form_2015 FORM
2015
1. Please describe your relationship with the applicant, including the frequency of your observations, interactions,
conversations or work with the applicant.
ELP-Nominator-Form_2015 FORM
2015
2. From your personal knowledge or observation, please list some of the significant contributions that the applicant has
made to his or her professional field that demonstrate leadership capacity. Take into consideration critical thinking
capabilities, adaption to new learning models, or creative problem solving skills.
3. In what ways will the applicant have an immediate or near-future opportunity to apply the leadership knowledge and
skills gained from participation in Emerging Leader Program?
ELP-Nominator-Form_2015 FORM
2015
4. What is the applicant’s strongest leadership quality which distinguishes and qualifies him/her for selection to
participate in the Emerging Leader Program?
5. In what way do you foresee your nominee contributing to the development of your lab’s workforce and the quality of
your services?
Please complete the following checklist:
ELP-Nominator-Form_2015 FORM
2015
Please rate the applicant with respect to the following leadership characteristics. Use a scale of 1-10, 1 meaning almost
never to 10 meaning almost always.
Trait
Exemplifies integrity in interactions and
activities
Fosters a culture that continuously assesses
change opportunities for sustaining the mission
Exhibits active listening during the dialogue
exchange
Fosters a culture of staff engagement and
commitment
Integrates strategic thinking into decisions and
long term planning regarding laboratory
operations
Displays high integrity and honesty
Fosters partnerships with key stakeholders to
promote the health of populations affected by
laboratory services
Rate 1-10
Trait
Creates a workplace environment that
encourages teamwork and collaboration
Applies critical thinking to develop
effective solutions to problems
Fosters an environment that integrates
systems thinking
Fosters a culture that ensures staff
recognition
Exemplifies the mission, vision and values
for the laboratory
Rate 1-10
Communicates information and feedback
to colleagues and management staff
Strengthens others and self by developing
competence
Signature: With my signature I hereby declare that the information provided on this application is correctly represented to the best
of my knowledge.
Signature
Title
Date