PIPEX Examiner Data Form
Examiner Data Form for the Board of Examiners
Preference *
Section I. Summary Information, Self-Assessment, and Preferences
Last Name *
Your answer
First Name *
Your answer
Your answer
Employer *
Your answer
Job Title
Your answer
Length of Tenure with this Title
Your answer
Supervisor Manager Name
Your answer
Work Address
Work Address *
Your answer
Work City *
Your answer
Work State *
Your answer
Work Zip *
Your answer
Work Phone *
Your answer
Home Address
Home Address *
Your answer
Home City *
Your answer
Home State *
Your answer
Home Zip *
Your answer
Home Phone *
Your answer
Personal Cell *
Your answer
Preferred Method of Contact *
Preferred Text Message Number
Primary Email *
Your answer
Secondary Email
Your answer
Preferred Email Address *
Have you ever worked for a small business? *
Have you ever been an Examiner for PiPEx/MassExcellence or Baldrige before? *
Indicate the years that you served as an examiner
Your answer
Preferred name for name tag *
Your answer
Would you like to receive a framed certificate honoring your service as an examiner at the end of the Examiner cycle? *
Preferred name for certificate *
Your answer
Self-Assessment Part I *
Please indicate your self assessment of your ability to evaluate an organization in the seven categories of the Partners in Performance Excellence (Baldrige) Criteria. This will primarily be used to build a profile of our Examiners’ strengths so that we can build balanced teams.
Somewhat Qualified
Highly Qualified
Leading Expert
Strategic Planning
Customer and Market Focus
Information and Analysis
Human Resource Development and Management
Process Management
Organization Results
Self Assessment Part II *
Indicate your self assessment of your expertise in these areas
Very Little
Satisfactory -
Satisfactory +
Highly Satisfactory
Broad expertise and experience in quality or process improvement
Broad expertise and experience in business, healthcare or education
Analytical skills
Verbal skills
Writing skills
Work as a team
Leadership skills
Section II. Education, Assessment/Evaluation and Work History
Organizational Assessment/Evaluation Experience
Describe any experience in evaluating an organization, including the criteria used (Baldrige, company-specific, ISO9000, The Joint Commission, or other accreditation, certification or regulatory agency criteria).
Your answer
Work History
Provide bio/resume information here, beginning with your current or most recent position. Include education information. OR you may email a resume instead of filling out this Section. Email it to Michelleeddya@comcast.net
Your answer
Never submit passwords through Google Forms.
This form was created inside of Loebig Ink, LLC.