Attachment_10_Required_Background_Investigation_Information_Form_(e-QIP).pdf

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service - Indian Health Service

Required Background Investigation Information

Executive Orders 10450, 12968, and HSPD-12 require a background investigation as a condition of employment. This investigation will be processed utilizing the US Office of Personnel Management (OPM), Electronic Questionnaire for Investigation Processing (eQIP) system. Please provide the information requested so that you can be initiated into eQIP. After you are initiated you will receive an email that will include the eQIP website link, instructions and additional forms required for the investigation.

Please provide your completed information to your servicing Human Resources Specialist, or Area Personnel Security Representative.

FACSIMILE TRANSMITTAL

TO: Human Resource Specialist or Area Personnel Security Representative From: ___________________________

Fax Number: 503 414-7735 ( located in the HR office in Portland Area )

Applicant Background Information

Please indicate the type of employee (Check One): Civil Svc_______Civil Svc E-HIRE________Contractor______CO_______Student/Volunteer________

Full Legal Name – Last, First, Middle (Include your full Middle Name, if no Middle Name - please state NMN)

Date of Birth (MM/DD/YYYY)

Social Security Number (XXX-XX-XXXX) Place of Birth (City, State)

Email Address Position Title

Duty Location (City, State) Area Office/Service Unit/Facility

CAN Number Type/Level of Investigation

NACI, CNACI, MBI (Public Trust V - moderate risk), BI (Public Trust VI – High Risk)

Federal Sponsor (Print Name)________________________________________________

Signature________________________________________ Date______________________________________________

Project officers are required to complete the below fields for contractors only

Contract Name: Contract Number:

Contract Begin Date: Contract End Date:

Project Officer (Print Name) _________________________________________

Signature________________________________________ Date__________________________

Confidentiality Notice: This fax is intended for the use of the person or office to whom it is addressed, and contains privileged or confidential information protected by law. All recipients are hereby notified that inadvertent or unauthorized receipt does not waive such privilege, and that unauthorized dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please destroy the attached document(s) and notify the sender by calling the number listed above. Thank you.

To be completed by the Area personnel security office

___________________________________Authentication Code

______________Date: Prints submitted by EWS____ Mailed to OPM_____ ______________Date eQIP emailed to App.

______________Date Suitability Issue/email sent to App.

______________Date sent print results to CSD and SU

_____________Date sent reminder to Applicant

_____________Date eQIP sent to OPM

_____________Date OF306 sent to CSD

OIG Check list is checked by CSD/ACQ and Supervisor before allowing a start date.