Green Belt Nomination and Declaration Form

A General
A1 Name (First-Middle-Last)
A2 Gender
A3 Designation
A4 Date of Birth (dd-mm-yyyy)
A5 Department
A6 Directly reporting to
A7 Whether working in shifts
A8 Education
A9 e-mail id
A10 Mobile no.
A11 Land line contact no. (Office)
A12 Land line contact no. (Res)
B Remarks
B1 Yes No
B2 Yes No
B3 Yes No
B4 Yes No
B5 Yes No
C
C1
C2
C2.1 Yes No
C2.2 Yes No
C2.3 Yes No
C2.4 Yes No
C2.5 Yes No
C2.6 Yes No
C3
C3.1 Yes No
C3.2 Yes No
C3.3 Yes No
C3.4 Yes No
C3.5 Yes No
C3.6 Yes No
D
D1 Yes No
D2 Yes No
D3 Yes No
D4 Yes No
E
E1 Yes No
E2 Yes No
E3 Yes No
E4 Yes No
E5 Yes No
E6 Yes No
E7 Yes No
E8 Yes No
Data Entry
Data Manipulation (Sorting/ Filtering)
Quality and Problem solving Training
Any formal training on six sigma ? (Described type & duration if yes)
Any formal training on application of 7 QC tools?
Any formal training on ISO9001 QMS?
Any formal training on DOE techniques?
Preparation of organization Chart
Any formal training on pokayoke/ Mistake proofing?
Computer operation and application Training
Any formal training on computer operation and application
Knowledge of MS Excel
Resources
Whether internet/ intranet facilities available in office and accessible?
Whether internet facility available at your home?
Graphs Generation
Satistical Calculation
Use of Pivot Table
Knowledge of MS Powerpoint
Slide preparation and presentation
Animation
Use of drawing tools
Cell Formating
Whether computer available in the department and accessible to you?
Whether computer available at your home?
Male/ Female
Graphs Insertion
Image/ Picture insertion
Your availability in day time at least once in a week for project guidance by QGS
Review the progress of project execution with Champion once a week
Not to allow positional and departmental barrier within team
Do you agree and give your consent to the following:
Interested to become a Six Sigma Green Belt
Devote 10 hours/ week on project execution (apart from training days)
Lead and guide the project team for one year
Maintain daily project log and send weekly progress report to QGS
Your total availability in day time during training
QGS-BSL-0901-00 PAGE 1OF 3
Green Belt Nomination and Declaration Form
A
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
B
B1 Yes No
B2 Yes No
B3 Yes No
B4 Yes No
B5 Yes No
B6 Yes No
a. Top 25% b. Top 50% c. Other
Recommendation by Champions
Shall allow him/ her to meet QGS Consultant once a week for guidance
Comfort level with computer
Capability to face challenges
Learning attitude a. Good b. Average c. Poor
Leadership and team player
Signature of Green Belt (Nominee) Date:
a. Good b. Average c. Poor
Last two year's performance (Tick correct)
Open minded
Analytical capability
Approach
Agree : Disagree:
a. Excellent b. Good c. Average d. Poor
a. Positive b. Neutral c. Negative
Technical Skill
Name of the nominee
Department
Key Remarks:
Conclusion: Nomination Accepted/ Declined
LEAD MASTER BLACK BELT
Date:
Evaluation
Consent
I/ we recommend/ do not recommend Mr./ Ms.. for
his/ her nomination and training for Six Sigma Green Belt.
Project Champion Department Head/ Nodal Champion
Date: Date:
For use by QGS Master Black Belt:
a. Good b. Average c. Poor
a. Good b. Average c. Poor
a. Good b. Average c. Poor
a. Good b. Average c. Poor
Dedication to responsibilities a. Good b. Average c. Poor
Management Skill
Shall review his/ her project progress at defined frequency
Shall provide necessary support as and when needed
Shall ensure his/ her total availability during training
Shall ensure and allow him/ her to devote 10 hours / week on project
Shall make available necessary infrastructure (Computer, internet etc)
QGS-BSL-0901-00 PAGE 2OF 3
Green Belt Nomination and Declaration Form
Nomination No.:
QGS-BSL-0901-00 PAGE 3OF 3