Free 00922.PDF - Indiana

SUBMISSION TO INDIANA STATE EMPLOYEE SUGGESTION PROGRAM
State Form 922 (R4 / 1-00)

FOR OFFICE USE ONLY

Name(s)

Agency / division / work unit

Work address (building, number, street, city, state, ZIP code)

Work telephone number ( )

Position / title

Agency with authority to implement your suggestion

Subject of your suggestion:

Descibe the present situation which will be affected by your suggestion

Describe your proposed solution and benefits (continue on back and / or attach additional sheet(s), if necessary)

The State of Indiana encourages and rewards state employees whose innovative ideas improve efficiency and effectiveness of government and provides state managers with a tool to recognize employees whose creative ideas have improved the way we do business.

It is understood and agreed that the State of Indiana's only obligation to me upon receiving and adopting this suggestion shall be determined solely by the terms and the rules of the Indiana Employee Suggestion Program in effect on the date of receipt of this suggestion by the State Personnel Department.
Your signature Date (month, day, year)

Thank you for exercising your power of Suggestion! Please allow 90 days for processing this suggestion. Direct any questions to the Suggestion Coordinator in the State Personnel Department at (317) 233-5519. Sign the completed form and mail to: Special Projects, State Personnel Department, 402 West Washington, Room W161, Indianapolis, Indiana 46204

USE THIS AREA TO EXPAND ON STATEMENTS YOU MADE ON THE FRONT OF THIS APPLICATION AND / OR ATTACH ADDITIONAL SHEET(S), IF NECESSARY

If your suggestion results in a "tangible" savings, please fill out the lower portion of this form as completely as possible. Your assistance in identifying the savings will help to accelerate the review process. 1. PRESENT COSTS Amount Labor Supplies / Equipment Printing Utilities / Services Postage Other TOTAL ESTIMATED PRESENT COSTS (1) 2. PROPOSED COSTS Amount Labor Supplies / Equipment Printing Utilities / Services Postage Other TOTAL ESTIMATED PROPOSED COSTS (2) 3. SAVINGS Present Total Costs (1) Proposed Total Costs (2) EQUALS 1ST YEAR SAVINGS (3) (-) (=) 4. IMPLEMENTATION COSTS Amount Labor Supplies / Equipment Printing Utilities / Services Postage Other TOTAL ESTIMATED IMPLEMENTATION COSTS (4) 5. NET SAVINGS 1ST YEAR SAVINGS (TOTAL FROM 3 ABOVE) IMPLEMENTATION COSTS (TOTAL FROM 4 ABOVE) EQUALS NET SAVINGS* (-) X Cost = Annual Expense X Cost = Annual Expense X Cost = Annual Expense

The net savings during the first year of implementation will be the basis for any monetary award. In determining the amount of any award, the suggestion committee will use the following formula: For Savings of $100,000 or lower, the amount of the award will be 5% of the first year's savings. For Savings of $100,000 to $200,000, the award will be 5% of the first $100,000 plus 2.5% of the following $100,000. For Savings above $200,000, the award will be 5% of the first $100,000 plus 2.5% of the following $100,000 plus 1% of the savings above $200,000. In any event, the maximum award will not exceed $13,000.