S06 - Att1 Hines Standard Documents.pdf
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- Solicitation number
- 36C25227Q0013
About this file
This document is Attachment 1 to a federal contract opportunity package containing standard documents and forms required for an Architect-Engineer (A/E) design services contract at Edward Hines Jr. VA Hospital in Hines, Illinois.
The attachment includes 24 standard documents and forms organized for A/E design projects. Key documents comprise: (1) VA Form 10-6298 A/E Fee Proposal Spreadsheet with detailed cost breakdowns for four project phases—Investigative Services/Schematic Design, Design Development, Construction Documents, and Construction Period Services/Site Visits—including line items for salary costs by discipline (architects, engineers, drafters, estimators, project managers), miscellaneous costs, overhead, profit, and incidental costs such as travel and per diem; (2) Contractor Badging Fingerprint Request Form (2025) requiring two original IDs and biometric enrollment; (3) No Smoking Policy (effective October 1, 2019) prohibiting all tobacco and vaping products on VA campus; (4) Hines VA Campus Site Plan; (5) Contractor Parking guidelines; (6) Underground Utility Plan; (7) Pre-Construction Checklist addressing contractor authority, progress schedules, payment procedures, protection of surrounding areas, safety authority, changes procedures, and subcontractor requirements; (8) Safety and Health During Construction Activities Policy (578-12-138A-076 R-2) establishing construction safety program requirements, responsibilities for Hospital Director, Engineering Service leadership, Construction Safety Officers, and contractors, including mandatory 30-hour OSHA training and infection control risk assessments; and (9) Optional Form 306 Declaration for Federal Employment with sections on military service, background information, criminal history, and federal debt delinquency. The documents establish mandatory compliance requirements for construction safety, personnel screening, environmental protection, and cost estimation methodologies for A/E services on federal VA projects.
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Attachment 1
Hines Standard Documents
February 26, 2025
Below is list of standard documents the COR has included with this package. Please request a file in its native format if needed.
Documents: 1) A/E Fee Proposal Spreadsheet 6298
2) Contractor Badging - Fingerprint Request Form 2025
3) No Smoking Policy 10-1-19
4) Hines VA Campus Site Plan
5) Contractor Parking
6) Hines Underground Utility Plan
7) Pre-Construction Checklist
8) Safety and Health during Construction Activities
A Pre-construction/Safety Risk Assessment (PCRA) B National Environmental Protection Act Assessment (NEPA) C Construction Safety Checklist D GEMS Awareness Competent Person Training E Construction Project Waste Minimization Report F Hines VAH Contractor Safety Disciplinary Procedure G Hines VAH COR Letter of Concern for Safety Non-Compliance H OSHA Required Competent Person Inspections I Crane Operation and Minimum Criteria On-Site Inspection Checklist J Hines VA Hospital Planned Critical Lift Plan & Crane Permit
9) Cutting Welding and Other Hot Work
10) Dig Permit SOP Form
11) Above Ceiling Entry and Wall Construction Permits
12) Pre-Construction Risk Assessment (PCRA 1.1)
13) Infection Control Risk Assessment (ICRA 1.3)
14) Interim Life Safety Measures (ILSM)
15) A/E Design Checklist
16) VA Review Template
17) Fire Protection Code Reviews
18) Infection Control Barrier Sample
19) NEPA Simple Form
20) Basis of Design Identifications
21) OIT Horizontal Cable Requirements
22) SOW Requirements for Hines A/C Shop
23) Hines VA Masking and Visitation Policy
Document 1
OMB Number 2900-0208 Estimated Burden: 4 hours
A/E VA
GENERAL
PHASING
ARCHITECTURAL
SITE AND LANDSCAPING
STRUCTURAL AND BORINGS
FIRE PROTECTION
HEATING AND AIR CONDITIONING
PLUMBING
ELECTRICAL
1A 1B 1C 1D 1E 1F 1G 1H 1I 1J
2A 2B 2C 2D 2E 2F 2G Specification / Technical Writer 2H Senior Cost Estimator 2I Drafter / CADD Technician 2J 2K 2L 2M
3A 3B 3C 3D 3E Specification / Technical Writer 3F Senior Cost Estimator 3G Drafter / CADD Technician 3H 3I 3J 3K
4A 4B 4C Specification / Technical Writer 4D Senior Cost Estimator 4E Drafter / CADD Technician 4F 4G 4H
4I SUBTOTAL
Administrative Assistant
Administrative Assistant
SUBTOTAL
Junior Fire Protection Engineer
Junior Environmental Engineer
Junior Landscape Architect Senior Project Environmental Engineer
Junior Civil Engineer Senior Project Landscape Architect
SITE AND LANDSCAPING
Senior Project Civil Engineer
SUBTOTAL
Administrative Assistant
Senior Cost Estimator Drafter / CADD Technician
Junior Interior Designer Specification / Technical Writer
Junior Architect Senior Project Interior Designer
ARCHITECTURAL
Senior Project Architect
A. SALARY COSTS HOURLY
SALARIES
LINE
NO.
EMPLOYEE-HOURS
A/E VAA/E VA
PROJECT TITLE AND LOCATION
PART I - INVESTIGATIVE SERVICES / SCHEMATIC DESIGN
COSTS
ARCHITECT - ENGINEER FEE PROPOSAL
Investigative Services / Schematic Design
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 4 hours. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This form or other agreed upon format, is used by VA Resident Engineers to supervise your work and verify the work progression so that you may be paid.
ESTIMATED NUMBER OF CONTRACT DRAWINGS DATE
NAME OF ARCHITECT / ENGINEER
TOTAL NUMBER OF DRAWINGS
Junior Geotechnical Engineer
Senior Project Structural Engineer
Administrative Assistant
STRUCTURAL AND BORINGS
SUBTOTAL
Senior Project Geotechnical Engineer Junior Structural Engineer
FIRE PROTECTION
Senior Project Fire Protection Engineer
VA FORM 10-6298
Aug 2018 (R) INVESTIGATIVE SERVICES / SCHEMATIC DESIGN Page 1 of 15
Estimated Burden: 4 hoursA/E A/E VA
5A 5B 5C Specification / Technical Writer 5D Senior Cost Estimator 5E Drafter / CADD Technician 5F 5G 5H 5I
6A 6B 6C Specification / Technical Writer 6D Senior Cost Estimator 6E Drafter / CADD Technician 6F 6G 6H 6I
7A 7B 7C Specification / Technical Writer 7D Senior Cost Estimator 7E Drafter / CADD Technician 7F 7G 7H 7I
8A 8B 8C 8D 8E
9A 9B 9C 9D 9E 9F 9G 9H 9H
11A Project Manager 11B Project Designer 11C Junior Designer 11D 11E 11F
12A Project Manager 12B Project Designer 12C Junior Designer 12D 12E 12F
SUBTOTAL
COSTS
A/E VA A/E
A/E VA A/E VA A/E
SUBTOTAL
COSTS
NO.
DAYS VA
Senior Project Electrical Engineer
Senior Project Fire Protection Engineer Senior Project Mechanical Engineer
NO. PERS.
REQUIRED
TOTAL SALARY COSTS
B. MISCELLANEOUS SALARY COSTS
VA A/E VANO.
DAYS
DESIGN STAFF SITE TRIPSLINE
NO.
EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES
DESIGN REVIEW TRIPS EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIESNO. PERS.
REQUIRED
Administrative Assistant
Junior Electrical Engineer
Principal
Senior Project Civil Engineer
Senior Project Electrical Engineer
Senior Project Plumbing Engineer
QA/QC REVIEWS
Senior Project Architect
Senior Project Structural Engineer
PROJECT MANAGEMENT
SUBTOTAL
PLUMBING
Senior Project Plumbing Engineer
SUBTOTAL
SUBTOTAL
SUBTOTAL
Administrative Assistant
ELECTRICAL
Administrative Assistant
Junior Plumbing Engineer
SUBTOTAL
LINE
NO.
Senior Project Mechanical Engineer
PART I - INVESTIGATIVE SERVICES / SCHEMATIC DESIGN (Continued)
COSTS
VAA. SALARY COSTS EMPLOYEE-HOURS
HEATING AND AIR CONDITIONING
Senior Project Manager Project Manager
HOURLY
SALARIES
Junior Mechanical Engineer
Aug 2018 (R) INVESTIGATIVE SERVICES / SCHEMATIC DESIGN Page 2 of 15
13A 13B 13C 13D 13E 13F 17 10.00
19A 19B 19C 19D 19E 19F
20A 20B 20C 20D 20E 20F
21A 21B 21C 21D 21E 21F
22A 22B 22C 22D 22E 22F
23A 23B 23C 23D 23E 23F
24A 24B 24C 24D 24E 24F
*Design Staff Site Trips = trips for site surveying, meeting with CORs/End Users to gather data/input, etc.
*The SoW will dictate how many Design Staff Site Trips & Design Review Trips are anticipated for the design project. The COR, CO and the AE will negotiate final number of trips and disciplines needed for those trips.
*Design Review Trips = trips for the AE to present deliverables of a particular phase as an on-site meeting
*The 6% fee limitation does not apply to Investigative Services / Schemate Design. See VAAR 836.606-73 for further details.
TOTAL INCIDENTAL COSTS
*TOTAL INVESTIGATIVE SERVICES / SCHEMATIC DESIGN COSTS - (LINE 18 +25)
NOTES:
COSTS
SUBTOTAL
COSTS
A/E VA
First Second Third
COSTS
SUBTOTAL
EMPLOYEE-HOURS
[OTHER TYPES OF INCIDENTALS]
VA
SURVEYS / INVESTIGATIONS, as applicable
Second
DESIGN STAFF SITE TRIPS
DETAILED DESCRIPTION OF INCIDENTAL
PER DIEM
SUBTOTAL
Fourth
DESIGN REVIEW TRIPS
SUBTOTAL
A/E VA A/E
PROFIT %
TOTAL SALARY PROPOSAL - (Lines 15 + 16 + 17)
C. INCIDENTAL COSTS
TOTAL MISCELLANEOUS SALARY COSTS
First
NO. PERS.
REQUIRED
COSTS
EMP. TRIPS
A/E VA
SUBTOTAL
NO.
DAYS
NO. PERS.
REQUIRED
Fourth
VA A/EA/E
C. INCIDENTAL COSTS (Continued)
COSTS
VA
DETAILED DESCRIPTION OF INCIDENTAL
TRAVEL COSTS EMP. TRIPS PER DIEM
Third
EMP. TRIPS
First Second
[OTHER TYPES OF TRIPS]
A/E VA
A/E A/E
TOTAL SALARY COSTS - (Lines 10 + 14)
OVERHEAD % OF LINE 15
VA A/E VA
TRAVEL COSTS
[OTHER TYPES OF TRIPS]
A/E
VA
HOURLY
SALARIES
COSTS
A/E
A/E VA
A/E VA
COSTS
A/E
B. MISCELLANEOUS SALARY COSTS (Continued)
EMPLOYEE-DAYS
A/E VAVANO.
DAYS
DETAILED DESCRIPTION OF INCIDENTAL
EMP. TRIPS PER DIEM
VA
NO. PERS.
REQUIRED A/E
REMARKS
VAVA A/E VA
LINE
NO.
EMP. TRIPS TRAVEL COSTS EMP. TRIPS
Third
NO.
DAYS
NO.
DAYS
NO. PERS.
REQUIRED
Fourth
REPRODUCTION OF REVIEW DOCS, as applicable
Aug 2018 (R) INVESTIGATIVE SERVICES / SCHEMATIC DESIGN Page 3 of 15
A/E VA
GENERAL
PHASING
ARCHITECTURAL
SITE AND LANDSCAPING
STRUCTURAL AND BORINGS
FIRE PROTECTION
HEATING AND AIR CONDITIONING
PLUMBING
ELECTRICAL
1A 1B 1C 1D 1E 1F 1G 1H 1I 1J
2A 2B 2C 2D 2E 2F 2G Specification / Technical Writer 2H Senior Cost Estimator 2I Drafter / CADD Technician 2J 2K 2L 2M
3A 3B 3C 3D 3E Specification / Technical Writer 3F Senior Cost Estimator 3G Drafter / CADD Technician 3H 3I 3J 3K
4A 4B 4C Specification / Technical Writer 4D Senior Cost Estimator 4E Drafter / CADD Technician 4F 4G 4H 4I
A/E VA
$0.00 Junior Architect $0.00
ARCHITECTURAL
Senior Project Architect
ARCHITECT - ENGINEER FEE PROPOSAL
Design Development
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 4 hours. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This form or other agreed upon format, is used by VA Resident Engineers to supervise your work and verify the work progression so that you may be paid.
ESTIMATED NUMBER OF CONTRACT DRAWINGS DATE
PROJECT TITLE AND LOCATION
Senior Project Interior Designer $0.00
PART II - DESIGN DEVELOPMENT
COSTS
NAME OF ARCHITECT / ENGINEER
TOTAL NUMBER OF DRAWINGS
HOURLY
SALARIES
LINE
NO.
A/E VA
EMPLOYEE-HOURS
A. SALARY COSTS
Junior Interior Designer $0.00 Specification / Technical Writer $0.00 Senior Cost Estimator $0.00 Drafter / CADD Technician $0.00 Administrative Assistant $0.00
SUBTOTAL
SITE AND LANDSCAPING
Senior Project Civil Engineer $0.00 Junior Civil Engineer $0.00 Senior Project Landscape Architect $0.00 Junior Landscape Architect $0.00
$0.00 $0.00
Administrative Assistant $0.00
Senior Project Environmental Engineer $0.00 Junior Environmental Engineer $0.00
$0.00
SUBTOTAL
STRUCTURAL AND BORINGS
Senior Project Structural Engineer $0.00 Junior Structural Engineer $0.00 Senior Project Geotechnical Engineer $0.00
$0.00 Administrative Assistant $0.00
Junior Geotechnical Engineer $0.00 $0.00 $0.00
SUBTOTAL
FIRE PROTECTION
Senior Project Fire Protection Engineer $0.00
$0.00 Administrative Assistant $0.00
Junior Fire Protection Engineer $0.00 $0.00 $0.00
SUBTOTAL
Aug 2018 (R) INVESTIGATIVE SERVICES / SCHEMATIC DESIGN Page 4 of 15
5A 5B 5C Specification / Technical Writer 5D Senior Cost Estimator 5E Drafter / CADD Technician 5F 5G 5H 5I
6A 6B 6C Specification / Technical Writer 6D Senior Cost Estimator 6E Drafter / CADD Technician 6F 6G 6H 6I
7A 7B 7C Specification / Technical Writer 7D Senior Cost Estimator 7E Drafter / CADD Technician 7F 7G 7H 7I
8A 8B 8C 8D 8E
9A 9B 9C 9D 9E 9F 9G 9H 9I
11A Project Manager 11B Project Designer 11C Junior Designer 11D 11E 11F
12A Project Manager 12B Project Designer 12C Junior Designer 12D 12E 12F
Administrative Assistant $0.00
$0.00
PLUMBING
Senior Project Plumbing Engineer $0.00
$0.00
PART II - DESIGN DEVELOPMENT (Continued)
LINE
NO. A. SALARY COSTS EMPLOYEE-HOURS HOURLY
SALARIES
COSTS
VA
$0.00 $0.00
Administative Assistant $0.00
HEATING AND AIR CONDITIONING
Senior Project Mechanical Engineer $0.00 Junior Mechanical Engineer $0.00
$0.00
Junior Plumbing Engineer $0.00 $0.00
SUBTOTAL
$0.00 $0.00 $0.00
SUBTOTAL
ELECTRICAL
Senior Project Electrical Engineer $0.00 Junior Electrical Engineer $0.00
Administrative Assistant $0.00
SUBTOTAL
PROJECT MANAGEMENT
Principal $0.00 Senior Project Manager $0.00 Project Manager $0.00
SUBTOTAL
QA/QC REVIEWS
Senior Project Architect $0.00 Senior Project Civil Engineer $0.00 Senior Project Structural Engineer $0.00 Senior Project Fire Protection Engineer $0.00
COSTS
Senior Project Mechanical Engineer $0.00 Senior Project Plumbing Engineer $0.00
A/E VA
SUBTOTAL
TOTAL SALARY COSTS
B. MISCELLANEOUS SALARY COSTS
Senior Project Electrical Engineer $0.00
LINE
NO.
DESIGN STAFF SITE TRIPS EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES A/E VA
$0.00
NO.
DAYS
NO. PERS.
REQUIRED A/E VA
$0.00 $0.00
SUBTOTAL
DESIGN REVIEW TRIPS EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA
SUBTOTAL
$0.00 $0.00 $0.00
Aug 2018 (R) INVESTIGATIVE SERVICES / SCHEMATIC DESIGN Page 5 of 15
13A 13B 13C 13D 13E 1 13F 17 10.00
19A 19B 19C 19D 19E 19F
20A 20B 20C 20D 20E 20F
21A 21B 21C 21D 21E 21F
22A 22B 22C 22D 22E 22F
23A 23B 23C 23D 23E 23F
24A 24B 24C 24D 24E 24F
B. MISCELLANEOUS SALARY COSTS (Continued)
[OTHER TYPES OF TRIPS] EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA
SUBTOTAL
TOTAL MISCELLANEOUS SALARY COSTS
TOTAL SALARY COSTS - (Lines 10 + 14)
OVERHEAD % OF LINE 15
PROFIT %
TOTAL SALARY PROPOSAL - (Lines 15 + 16 + 17)
C. INCIDENTAL COSTS
LINE
NO.
DESIGN STAFF SITE TRIPS EMP. TRIPS TRAVEL COSTS EMP. TRIPS PER DIEM COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA A/E VA A/E VA
First Second Third Fourth
SUBTOTAL
DESIGN REVIEW TRIPS EMP. TRIPS TRAVEL COSTS EMP. TRIPS PER DIEM
A/E VA
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA A/E VA
First Second Third Fourth
SUBTOTAL
[OTHER TYPES OF TRIPS] EMP. TRIPS TRAVEL COSTS EMP. TRIPS PER DIEM
A/E VA
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA A/E VA
First Second Third Fourth
SUBTOTAL
C. INCIDENTAL COSTS (Continued)
REPRODUCTION OF REVIEW DOCS, as applicable DETAILED DESCRIPTION OF INCIDENTAL COSTS
RENDERINGS DETAILED DESCRIPTION OF INCIDENTAL COSTS
[OTHER TYPES OF INCIDENTALS] DETAILED DESCRIPTION OF INCIDENTAL COSTS
*TOTAL DESIGN DEVELOPMENT COSTS - (LINE 18 +25)
NOTES:
REMARKS
*The 6% fee limitation applies to Lines 1 - 21. It doesn't not include incidental costs for reproduction,etc. See VAAR 836.606-73 for further details.
*Design Review Trips = trips for the AE to present deliverables of a particular phase as an on-site meeting *The SoW will dictate how many Design Staff Site Trips & Design Review Trips are anticipated for the design project. The COR, CO and the AE will negotiate final number of trips and disciplines needed for those trips.
*Design Staff Site Trips = trips for site surveying, meeting with CORs/End Users to gather data/input, etc.
Aug 2018 (R) INVESTIGATIVE SERVICES / SCHEMATIC DESIGN Page 6 of 15
A/E VA
GENERAL
PHASING
ARCHITECTURAL
SITE AND LANDSCAPING
STRUCTURAL AND BORINGS
FIRE PROTECTION
HEATING AND AIR CONDITIONING
PLUMBING
ELECTRICAL
1A 1B 1C 1D 1E 1F 1G 1H 1I 1J
2A 2B 2C 2D 2E 2F 2G Specification / Technical Writer 2H Senior Cost Estimator 2I Drafter / CADD Technician 2J 2K 2L 2M
3A 3B 3C 3D 3E Specification / Technical Writer 3F Senior Cost Estimator 3G Drafter / CADD Technician 3H 3I 3J 3K
4A 4B 4C Specification / Technical Writer 4D Senior Cost Estimator 4E Drafter / CADD Technician 4F 4G 4H
4I SUBTOTAL
Administrative Assistant $0.00
$0.00 $0.00
Junior Fire Protection Engineer $0.00 $0.00
SUBTOTAL
FIRE PROTECTION
Senior Project Fire Protection Engineer $0.00
$0.00 Administrative Assistant $0.00
$0.00 $0.00
Senior Project Geotechnical Engineer $0.00 Junior Geotechnical Engineer $0.00
Senior Project Structural Engineer $0.00 Junior Structural Engineer $0.00
SUBTOTAL
STRUCTURAL AND BORINGS
Administrative Assistant $0.00
$0.00 $0.00
Junior Environmental Engineer $0.00 $0.00
Junior Landscape Architect $0.00 Senior Project Environmental Engineer $0.00
Junior Civil Engineer $0.00 Senior Project Landscape Architect $0.00
SUBTOTAL
SITE AND LANDSCAPING
Senior Project Civil Engineer $0.00
Administrative Assistant $0.00
Senior Cost Estimator $0.00 Drafter / CADD Technician $0.00
Junior Interior Designer $0.00 Specification / Technical Writer $0.00
Junior Architect $0.00 Senior Project Interior Designer $0.00
ARCHITECTURAL
Senior Project Architect $0.00
A. SALARY COSTS HOURLY
SALARIES
TOTAL NUMBER OF DRAWINGS
PART III - CONSTRUCTION DOCUMENTS
LINE
NO.
A/E VA
EMPLOYEE-HOURS
A/E VA
NAME OF ARCHITECT / ENGINEER
ARCHITECT - ENGINEER FEE PROPOSAL
Construction Documents
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 4 hours. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This form or other agreed upon format, is used by VA Resident Engineers to supervise your work and verify the work progression so that you may be paid.
ESTIMATED NUMBER OF CONTRACT DRAWINGS DATE
PROJECT TITLE AND LOCATION
COSTS
Aug 2018 (R) Page 7 of 15
5A 5B 5C Specification / Technical Writer 5D Senior Cost Estimator 5E Drafter / CADD Technician 5F 5G 5H 5I
6A 6B 6C Specification / Technical Writer 6D Senior Cost Estimator 6E Drafter / CADD Technician 6F 6G 6H 6I
7A 7B 7C Specification / Technical Writer 7D Senior Cost Estimator 7E Drafter / CADD Technician 7F 7G 7H 7I
8A 8B 8C 8D 8E
9A 9B 9C 9D 9E 9F 9G 9H 9I 10 $0.00
11A Project Manager 11B Project Designer 11C Junior Designer 11D 11E 11F
12A Project Manager 12B Project Designer 12C Junior Designer 12D 12E
12F SUBTOTAL
$0.00
$0.00 $0.00
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA
$0.00 $0.00
A/E
SUBTOTAL
DESIGN REVIEW TRIPS EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES
$0.00
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA
SUBTOTAL
TOTAL SALARY COSTS
B. MISCELLANEOUS SALARY COSTS
LINE
NO.
DESIGN STAFF SITE TRIPS EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES
COSTS
VA
Senior Project Mechanical Engineer $0.00 Senior Project Plumbing Engineer $0.00
Senior Project Civil Engineer $0.00 Senior Project Structural Engineer $0.00 Senior Project Fire Protection Engineer $0.00
Senior Project Electrical Engineer $0.00
SUBTOTAL
QA/QC REVIEWS
Senior Project Architect $0.00
Senior Project Manager $0.00 Project Manager $0.00
SUBTOTAL
PROJECT MANAGEMENT
Principal $0.00
$0.00 Administrative Assistant $0.00
$0.00 $0.00
Senior Project Electrical Engineer $0.00 Junior Electrical Engineer $0.00
SUBTOTAL
ELECTRICAL
Administrative Assistant $0.00
$0.00 $0.00
Junior Plumbing Engineer $0.00 $0.00
PLUMBING
Senior Project Plumbing Engineer $0.00
SUBTOTAL
Administative Assistant $0.00
$0.00 $0.00
Junior Mechanical Engineer $0.00 $0.00
VA
HEATING AND AIR CONDITIONING
Senior Project Mechanical Engineer $0.00
PART III - CONSTRUCTION DOCUMENTS (Continued)
LINE
NO. A. SALARY COSTS EMPLOYEE-HOURS HOURLY
SALARIES
COSTS
Aug 2018 (R) Page 8 of 15
13A 13B 13C 13D 13E 13F 16 0 17 10
19A 19B 19C 19D 19E 19F
20A 20B 20C 20D 20E 20F
21A 21B 21C 21D 21E 21F
22A 22B 22C 22D 22E 22F
23A 23B 23C 23D 23E 23F
24A 24B 24C 24D 24E 24F
27 PART I:
28 PART II:
29 PART III:
30 $0.00
[OTHER TYPES OF INCIDENTALS] DETAILED DESCRIPTION OF INCIDENTAL COSTS
TOTAL A/E COST (Lines 27 + 28 + 29)
CAPITULATION OF A/E COSTS
INVESTIGATE SERVICES / SCHEMATIC DESIGN
DESIGN DEVELOPMENT
CONSTRUCTION DOCUMENTS
(WITHOUT CPS/Site Visits)
NOTES:
*The 6% fee limitation applies to Lines 1 - 21. It doesn't not include incidental costs for reproduction,etc. See VAAR 836.606-73 for further details.
*Design Staff Site Trips = trips for site surveying, meeting with CORs/End Users to gather data/input, etc.
*The SoW will dictate how many Design Staff Site Trips & Design Review Trips are anticipated for the design project. The COR, CO and the AE will negotiate final number of trips and disciplines needed for those trips.
*Design Review Trips = trips for the AE to present deliverables of a particular phase as an on-site meeting
*TOTAL - CONSTRUCTION DOCUMENTS COSTS - (LINE 18 +25)
COSTS
RENDERINGS DETAILED DESCRIPTION OF INCIDENTAL
SUBTOTAL
C. INCIDENTAL COSTS (Continued)
REPRODUCTION OF REVIEW DOCS, as applicable DETAILED DESCRIPTION OF INCIDENTAL COSTS
A/E VA
First Second Third Fourth
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA
SUBTOTAL
[OTHER TYPES OF TRIPS] EMP. TRIPS TRAVEL COSTS EMP. TRIPS PER DIEM
A/E VA
A/E VA
First Second Third Fourth
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA A/E VA
DESIGN REVIEW TRIPS EMP. TRIPS TRAVEL COSTS EMP. TRIPS PER DIEM
A/E VA
First Second Third Fourth
SUBTOTAL
TOTAL SALARY PROPOSAL - (Lines 15 + 16 + 17)
C. INCIDENTAL COSTS
LINE
NO.
DESIGN STAFF SITE TRIPS EMP. TRIPS TRAVEL COSTS EMP. TRIPS PER DIEM COSTS
A/E VA A/E VA A/E VANO.
DAYS
NO. PERS.
REQUIRED A/E VA A/E VA
SUBTOTAL
TOTAL MISCELLANEOUS SALARY COSTS
TOTAL SALARY COSTS - (Lines 10 + 14)
OVERHEAD % OF LINE 15
PROFIT %
VA A/E VA A/E VA
[OTHER TYPES OF TRIPS] EMPLOYEE-DAYS EMPLOYEE-HOURS HOURLY
SALARIES
COSTS
NO.
DAYS
NO. PERS.
REQUIRED A/E
B. MISCELLANEOUS SALARY COSTS (Continued)
Aug 2018 (R) Page 9 of 15
A/E VA
GENERAL
PHASING
ARCHITECTURAL
SITE AND LANDSCAPING
STRUCTURAL AND BORINGS
FIRE PROTECTION
HEATING AND AIR CONDITIONING
PLUMBING
ELECTRICAL
1A 1B 1C 1D 1E 1F 1G 1H 1I 1J
2A 2B 2C 2D 2E 2F 2G Specification / Technical Writer 2H Senior Cost Estimator 2I Drafter / CADD Technician 2J 2K 2L 2M
3A 3B 3C 3D 3E Specification / Technical Writer 3F Senior Cost Estimator 3G Drafter / CADD Technician 3H 3I 3J 3K
4A 4B 4C Specification / Technical Writer 4D Senior Cost Estimator 4E Drafter / CADD Technician 4F 4G 4H 4I
5A 5B 5C Specification / Technical Writer 5D Senior Cost Estimator 5E Drafter / CADD Technician 5F 5G 5H 5I
ARCHITECT - ENGINEER FEE PROPOSAL
Construction Period Services and Site Visits
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 4 hours. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This form or other agreed upon format, is used by VA Resident Engineers to supervise your work and verify the work progression so that you may be paid.
ESTIMATED NUMBER OF AS-BUILT CONTRACT DRAWINGS DATE
$0.00
Senior Project Landscape Architect $0.00 Junior Landscape Architect Senior Project Environmental Engineer $0.00
Senior Project Civil Engineer
Specification / Technical Writer
SITE AND LANDSCAPING
$0.00
Junior Civil Engineer
$0.00
$0.00
Administative Assistant
$0.00
PROJECT TITLE AND LOCATION
Junior Interior Designer $0.00
Junior Architect
HOURLY
SALARIES
TOTAL NUMBER OF AS-BUILT DRAWINGS
NAME OF ARCHITECT / ENGINEER
ARCHITECTURAL
A. SALARY COSTS
LINE
NO.
A/E
PART IV - CONSTRUCTION PERIOD SERVICES
VA A/E VA
1) Answering RFIs during Bidding (includes providing answers, amendment supporting docs, etc.)
2) Issuance of "For Construction Documents"
3) Post Award RFI, Submittal and Shop Drawing Reviews
4) Call-In Project Mtgs and All Other CPS Related Tasks Oultined in the Contract Procedures, excluding Site Visits/As-Built Dwgs.
EMPLOYEE-HOURS
Senior Project Architect $0.00
COSTS
$0.00
$0.00 $0.00
SUBTOTAL
$0.00Senior Project Interior Designer
Senior Cost Estimator Drafter / CADD Technician
$0.00
$0.00 $0.00 $0.00
$0.00
SUBTOTAL
$0.00
$0.00 Junior Geotechnical Engineer
$0.00
HEATING AND AIR CONDITIONING
$0.00
Junior Mechanical Engineer
Junior Fire Protection Engineer
$0.00
$0.00
Junior Environmental Engineer
FIRE PROTECTION
$0.00
$0.00
Administrative Assistant
$0.00 $0.00 $0.00
SUBTOTAL
$0.00
$0.00
Senior Project Structural Engineer
$0.00
Senior Project Fire Protection Engineer
SUBTOTAL
Administrative Assistant
$0.00 $0.00
$0.00
Administrative Assistant
SUBTOTAL
Senior Project Mechanical Engineer
$0.00
Administrative Assistant
STRUCTURAL AND BORINGS
$0.00
$0.00
Junior Structural Engineer Senior Project Geotechnical Engineer
Aug 2018 (R) Page 10 of 15
6A 6B 6C Specification / Technical Writer 6D Senior Cost Estimator 6E Drafter / CADD Technician 6F 6G 6H 6I
7A 7B 7C Specification / Technical Writer 7D Senior Cost Estimator 7E Drafter / CADD Technician 7F 7G 7H 7I
8A 8B 8C 8D 9 $0.00
A/E A/E VA
10A 10B 10C 10D 10E 10F 10G 10H
11A 11B 11C 11D 11E 11F 11G 11H 11I 11J
12A 12B 12C 12D 12E 12F 12G 12H
13A 13B 13C 13D 13E 13F
14A 14B 14C 14D 14E 14F
SUBTOTAL
Specification / Technical Writer
STRUCTURAL AND BORINGS
FIRE PROTECTION
$0.00
$0.00
$0.00
PART IV - CONSTRUCTION PERIOD SERVICES (Continued)
A. SALARY COSTS
Project Manager $0.00 Senior Project Manager
TOTAL SALARY COSTS
$0.00 Principal $0.00
$0.00
SUBTOTAL
Administrative Assistant $0.00
PROJECT MANAGEMENT
SUBTOTAL
ELECTRICAL
Senior Project Electrical Engineer $0.00
$0.00 $0.00
PLUMBING
LINE
NO.
1) Answering RFIs during Bidding (includes providing answers, amendment supporting docs, etc.)
2) Issuance of "For Construction Documents"
3) Post Award RFI, Submittal and Shop Drawing Reviews A/E VA
SUBTOTAL
SUBTOTAL
SITE AND LANDSCAPING
$0.00
Junior Landscape Architect
Specification / Technical Writer
$0.00 $0.00
Senior Project Civil Engineer
$0.00 $0.00
Senior Project Environmental Engineer Junior Environmental Engineer
$0.00
$0.00
Senior Project Landscape Architect
COSTS
VA
$0.00
B. RECORD (AS BUILT) DRAWINGS AND SPECIFICATIONS
SALARY COSTS
$0.00
$0.00 $0.00
$0.00
Drafter / CADD Technician
HOURLY
SALARIES
Senior Project Architect $0.00 Junior Architect
Junior Interior Designer Specification / Technical Writer
Senior Project Structural Engineer
$0.00
Specification / Technical Writer
Drafter / CADD Technician
Senior Project Fire Protection Engineer
$0.00Junior Structural Engineer Senior Project Geotechnical Engineer Junior Geotechnical Engineer
Drafter / CADD Technician
$0.00
$0.00 $0.00
$0.00
Junior Fire Protection Engineer $0.00
LINE
NO.
Drafter / CADD Technician
$0.00
HEATING AND AIR CONDITIONING
$0.00
SUBTOTAL
Drafter / CADD Technician
SUBTOTAL
Junior Mechanical Engineer Specification / Technical Writer
Senior Project Mechanical Engineer $0.00 $0.00
$0.00
A/E
COSTS
VA
EMPLOYEE-HOURS HOURLY
SALARIES
4) Call-In Project Mtgs and All Other CPS Related Tasks Oultined in the Contract Procedures, excluding Site Visits/As-Built Dwgs.
$0.00Administrative Assistant
$0.00
$0.00 Junior Plumbing Engineer $0.00
Junior Electrical Engineer
$0.00
$0.00
$0.00
Senior Project Plumbing Engineer
SUBTOTAL
Senior Project Interior Designer
ARCHITECTURAL
EMPLOYEE-HOURS
Junior Civil Engineer
Aug 2018 (R) Page 11 of 15
15A 15B 15C 15D 15E 15F
16A 16B 16C 16D 16E 16F
17A 17B 17C 17D 17E 18 $0.00 21 10.00
23A 23B 23C 23D 23E
24A 24B 24C 24D 24E
25A 25B 25C 25D 25E
VA A/E A/E VA
NO. INSP. NO. DAYS
NO. INSP. NO. DAYS
NO. MTGS
NO. INSP. NO. DAYS
NO. INSP. NO. DAYS
37 PROFIT 10.00
COSTSHOURLY
SALARIES
PART IV - CONSTRUCTION PERIOD SERVICES (CONTINUED)
$0.00
SUBTOTAL
29 0
PRE-CONSTRUCTION CONFERENCE (POST AWARD)
EMP. PER DAY
Detailed Description of Incidental
31 NO. VISITS, ONE EMPLOYEE-DAY EACH
SITE VISIT(S)
ON-SITE CONSTRUCTION PROGRESS MEETINGS
% OF LINE 35
TOTAL SALARY COSTS - (Lines 35 + 36 + 37)
SALARY COSTS - Site Visits
OVERHEAD
FINAL INSPECTION(S)
EMP. PER DAY 0
INTERMEDIATE A/C INSPECTION(S)
COSTS
EMP. TRIPS TOTAL HOURS
PLUMBING
LINE
NO.
B. RECORD (AS BUILT) DRAWINGS AND SPECIFICATIONS
SALARY COSTS VA
EMPLOYEE-HOURS
$0.00
SUBTOTAL
Project Manager
SUBTOTAL
PROFIT %
OVERHEAD % OF LINE 19
VA
TOTAL SALARY COSTS - (Lines 9 + 18)
Drafter / CADD Technician
$0.00
REPRODUCTION OF FOR CONSTRUCTION DWGS/SPE Detailed Description of Incidental
TOTAL SALARY COSTS - (Lines 19 + 20 + 21)
C. INCIDENTAL COSTS
$0.00 $0.00
TOTAL SALARY COSTS
Specification / Technical Writer
PROJECT MANAGEMENT
$0.00
Senior Project Manager Principal $0.00
$0.00
Drafter / CADD Technician
ELECTRICAL
Senior Project Plumbing Engineer Junior Plumbing Engineer
Senior Project Electrical Engineer
Specification / Technical Writer
$0.00 Junior Electrical Engineer $0.00
$0.00
EMP. PER DAY
SUBTOTAL
REPRODUCTION OF AS-BUILTS COSTS
COSTS
Detailed Description of Incidental
COSTS
SUBTOTAL
PRE-BID CONFERENCE (BIDDING PHASE)
HOURLY
SALARIES
[OTHER TYPES OF INCIDENTALS]
A/E
TOTAL CONSTRUCTION PERIOD SERVICES COSTS - (Lines 22+ 26)
REMARKS
PART V - SITE VISITS
28 EMP. PER DAY 0
LINE
NO. A. SALARY COSTS
INCIDENTAL COSTS
Aug 2018 (R) Page 12 of 15
Estimated Burden: 4 hoursA/E VA A/E VA A/E VA A/E VA A/E VA
NO. INSP. NO. DAYS
NO. INSP. NO. DAYS
NO. INSP. NO. MTGS
NO. INSP. NO. DAYS
NO. INSP. NO. DAYS
49 PART I:
50 PART II:
51 PART III:
52 PART IV:
PART V: SITE VISITS, 0 AT
ON-SITE CONSTRUCTION PROGRESS MEETINGS
PRE-BID CONFERENCE (BIDDING PHASE)
PRE-CONSTRUCTION CONFERENCE (POST AWARD)
SITE VISIT(S)
EMP. PER DAY
PART V - SITE VISITS (CONTINUED)
EMP. PER DAY
COSTSB. TRAVEL COSTS EMP. TRIPS TRAVEL COSTS PER DIEMEMP. DAYS
EMP. PER DAY
EMP. PER DAY
NO. VISITS, ONE EMPLOYEE-DAY EACH 0
BEHIND WALL - ABOVE CEILING INSPECTION(S)
FINAL INSPECTION(S)
CAPITULATION OF A/E PROPOSAL
TOTAL A/E COST (Lines 49 + 50 + 51 + 52 + 53)
TOTAL COSTS FOR SITE VISITS - (Lines 38 + 48)
(WITH CPS & SITE VISITS)
#DIV/0! PER VISIT
TOTAL TRAVEL COSTS
FOR A MAXIMUM OF: (Line 48)
INVESTIGATE SERVICES / SCHEMATIC DESIGN
DESIGN DEVELOPMENT
CONSTRUCTION DOCUMENTS
CONSTRUCTION PERIOD SERVICES - (Line 27)
EMP. PER DAY
Aug 2018 (R) Page 13 of 15
ARCHITECT - ENGINEER FEE PROPOSAL
Certifications
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 4 hours. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This form or other agreed upon format, is used by VA Resident Engineers to supervise your work and verify the work progression so that you may be paid.
Signature Date of Execution***
This is to certify that, to the best of my knowledge and belief, the cost or pricing data (as defined in section 2.101 of the Federal Acquisition Regulation (FAR) and required under FAR subsection 15.403-4) submitted, either actually or by specific identification in writing to the contracting officer or to the contracting officer's representative in support of __________* are accurate, complete,and current as of __________** . This certification includes the cost or pricing data supporting any advance agreements between he offeror and the Government that are part of the proposal.
PART VI - CERTIFICATIONS
CERTIFICATION OF CURRENT COST OR PRICING DATA
Name
NOTE: The Architect-Engineer shall check the certification below which is applicable to their enterprise, and if required, provide the necessary substantiating information.
□ CERTIFICATION OF CONCURRENT SUBMISSION OF DISCLOSURE STATEMENTS
Title
*Identify the proposal, request for price adjustment, or other submission involved, giving the appropriate identifying number (e.g., RFP no.).
** Insert the day, month, and year when price negotiations were concluded and price agreement was reached of, if applicable, an earlier date agreed upon between the parties that is as close as practicable to the date of agreement on price.
***Insert the day, month, and year of signing, which should be as close as practicable to the date when the price negotiations were concluded and the contract price was agreed to.
Firm
The offeror hereby certifies submission, as part of the proposal under this solicitation, copies of the Disclosure Statements as follows: (i) Original and one copyto the cognizant Contracting Officer; (ii) one copy to the cognizant contract auditor; and (iii) one copy to the Cost Accounting Standards Board, 441 G. Street NW, Washington, DC 20548
DATE OF DISCLOSURE STATEMENT NAME AND ADDRESS OF COGNIZANT CONTRACTING OFFICERS WHERE FILED
The offeror further certifies that practices used in estimating costs in pricing this proposal are consistent with the cost accounting practices in the Disclosure Statements.
□ CERTIFICATION FOR PREVIOUSLY SUBMITTED DISCLOSURE STATEMENTS
The offeror hereby certifies that the Disclosure Statements were filed as follows:
DATE OF DISCLOSURE STATEMENT NAME AND ADDRESS OF COGNIZANT CONTRACTING OFFICERS WHERE FILED
□ CERTIFICATION OF MONETARY EXEMPTION
The offeror hereby certifies that, together with all divisions, subsidiaries, and affiliates under common control, they did not (1) receive a single CAS-covered contract award if $10 million or more; (2) Receive $10 million or more in CAS-covered contracts during its preceding accounting period; (3) Receive less than $10 million in CAS-covered contract awards during its preceding cost accounting period but such awards were 10 percent or more of total sales.
DATE
DATE
CONCUR - SIGNATURE AND TYPED NAME OF CONTRACTING OFFICER DATE
DISTRIBUTION: (082A)-CC: AE and Proposed File
The offeror hereby certifies that practices used in estimating costs in pricing this proposal are consistent with the cost accounting practices disclosed in this Disclosure Statement.
CONCUR - SIGNATURE AND TYPED NAME OF ARCHITECT - ENGINEER
CONCUR - SIGNATURE AND TYPED NAME OF ARCHITECT - ENGINEER
CONCUR - SIGNATURE AND TYPED NAME OF ARCHITECT - ENGINEER
DATE
Jan 1999 (R) CERTIFICATIONS Page 14 of 15
VA Fee Estimate Summary Estimated Construction Budget (not including A/E costs) 6% Fee Limitation $0.00
Overhead 0.00% Profit 10.00%
Application of 6% Fee Limitation
Item Investigative Services
/ Schematic Design Design
Development Construction Documents
Construction Period Services Totals
Brooks Act Fee Limitation 6%
Part I, II, III: Preparation of Contract Drawings and Specifications Part A: Salary Costs $0 $0 − $0 Part B: Misc Salary Costs $0 $0 − $0 Total Salary Costs $0 $0 − $0
Overhead $0 $0 − $0 Profit $0 $0 − $0 Total Salary Proposal $0 $0 − $0 Part C: Incidential Costs $0 $0 − $0 (Design Staff Site Trips & Design Review Trips - excludes Reproduction, etc.) −
Total applied towards 6% $0 $0 $0 − $0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
AE Costs as a Percentage of Estimated Construction Budget
Item % of Construction
Cost Goal Dollar Goal Actual Overhead Profit Actual (w/OH+P) Actual % Total Prepare Construction Docs Design Cost $0 $0 $0 $0 $0 #DIV/0!
Misc. Salary Design Costs $0 $0 $0 $0 Mics. Incidental Design Costs $0 $0 Total Mics. Design Costs 1.50% $0 $0 #DIV/0!
Subtotal $0 $0 #DIV/0!
Part IV Construction Services Salary Costs $0 Part IV Incidental Construction Cost Part V Construction Site Visit Salary Costs 1.25% $0 Part V Incidental Site Visit Costs .
Total Construction Services Subtotal $0 $0 $0 #DIV/0!
TOTALS 0.00% $0 -$ #DIV/0!
Aug 2018 (R) Page 15 of 15
Document 2
2025 ENGINEERING SERVICE
PROJECT PLANNING CONTRACTOR
FINGERPRINT REQUEST FORM
Bring with you two (2) original IDs (Identity Source Documents).
Complete all yellow highlighted fields on this form to the best of your ability
Applicant Category: Check One (APPLICATION RENEWABLE IN 182 DAYS)
EMPLOYEE ✔ CONTRACTOR
HEALTH PROFESSONS TRAINEE,
resident (VHA intern, fellow, student)
AFFILIATE
VOLUNTEER
OTHER/CONTRACTED
EMPLOYEE
ENTER YOUR NAME EXACTLY AS IT APPEARS ON IDs
Name: (Last, First, Middle)
Other Last Names Used
SSN (use of pseudo number is not permitted)
Position Title
Telephone #
Date of Birth: (mm/dd/yyyy)
City/State and Country of Birth
E-Mail Address
Country of Citizenship
Dual Citizen?
VA Work Location
Name of Sponsor: Sponsor Phone:
Contractors Only: Company Name
Company Address/Work Email
Contract Start Date
Name of Project COR
Project #
Project End Date
FINGERPRINT LOCATION
Edward Hines Jr VAMC
FINGERPRINT DATE (mm/dd/yyyy)
PREVIOUS VA PIV CARD HOLDER (Yes/No)
GENDER (M/F)
HEIGHT (inches)
WEIGHT (US pounds)
HAIR COLOR
EYE COLOR
RACE/ETHNICITY
Facility Name Location:
Hines – 578 VISN 12
Facility SOI # Facility SON #
Date Cleared Signature
Comments
Mikel Jones, mikel.jones@va.gov 708 202-8387 ext 21322
PSAC-VACO 430H
Identifying documents NOT
ACCEPTED by USAccess include, but are not limited to:
1. Student ID Cards (including public/state universities, as well as private universities)
2. Gun or Firearms permits
3. License to Carry
4. Hunting/Fishing permits
5. Facility Badge
6. Temporary driver’s licenses
7. Selective service card
8. Company ID Card
9. Foreign Driver’s License (other than Canada)
10. Library Card
11. Temporary PIV Card
12. Marriage license
Primary Forms of Identification (Acceptable
Documents)
1. U.S. Passport or a U.S. Passport Card
2. Permanent Resident Card or an Alien Registration Receipt Card (Form I-
551)
3. Foreign passport
4. Employment Authorization Document that contains a photograph (Form I-
766)
5. Driver's license or an ID card issued by a state or possession of the United
States provided it contains a photograph
6. U.S. Military ID card
7. U.S. Military dependent's ID card; or
8. PIV Card.
Issue No. 20-
USAccess Deployment Bulletin
USAccess Identity Proofing Source Documents
Week of December 28, 2020
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Weekly Bulletin Archive
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Identifying Source
Documents Not Accepted for USAccess is Coming… Are You Ready?
Issue No. 20-45
USAccess Enrollment and Identity Proofing Documents
Secondary Forms of Identification (Acceptable
Documents)
1. U.S. Social Security Card issued by the Social Security Administration.
Laminated SSA cards cannot be used without Security Officer approval.
2. Original or certified copy of a birth certificate issued by a state, county, municipal authority, possession, or outlying possession of the United
States bearing an official seal
3. ID card issued by a federal, state, or local government agency or entity, provided it contains a photograph. EXCEPTIONS APPLY
4. Voter's registration card; 13. Reentry Permit (Form I-327)
5. U.S. Coast Guard Merchant Mariner Card
6. Certificate of U.S. Citizenship (Form N-560 or N-561)
7. Certificate of Naturalization (Form N-550 or N-570)
8. U.S. Citizen ID Card (Form I-197)
9. Identification Card for Use of Resident Citizen in the United States (Form I-
179)
10. Certification of Birth Abroad or Certification of Report of Birth issued by the
Department of State (Form FS545 or Form DS-1350)
11. Temporary Resident Card (Form I-688)
12. Employment Authorization Card (Form I-688A)
13. Reentry Permit (Form I-327)
14. Refugee Travel Document (Form I-571)
15. Employment authorization document issued by Department of Homeland
Security (DHS)
16. Employment Authorization Document issued by DHS with photograph
(Form I-688B)
17. Driver's license issued by a Canadian government entity
18. Native American tribal document.
The following rules apply to all presented identity source documents:
• All documents must be in their original forms - no photocopies other than a certified copy of birth certificate bearing an official seal.
• Expired or canceled identity documents are not a cceptable.
• All Primary forms of ID contain an expiration date;
however, some Secondary forms of ID do not. Not having an expiration date does not make a
Secondary ID Source unacceptable. Secondary forms of ID without an expiration date can be accepted.
• Up dating or replacing identity source documents is n o t required after successfully completing the id entity proofing process.
• If any of the identity source documents presented for identity proofing bear different names, then evidence of a formal name change must be provided linking the names. For example, a married woman with a current driver’s license and birth certificate can provide a marriage license.
Photos are required for all forms of primary identification documents.
mailto:vacohspd12pmo@va.gov http://vaww.oicam.va.gov/pscm/credential-management/communications/ mailto:vacohspd12pmo@va.gov?subject=Unsubscribe VHAHINDoyleL Text Box Real ID required
VHAHINDoyleL Text Box Real ID required
Form Approved:
OMB No. 3206-0182 Declaration for Federal Employment*
(*This form may also be used to assess fitness for federal contract employment)
Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. Before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.
All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).
Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").
Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.
Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.
Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.
ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.
Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
U.S. Office of Personnel Management
5 U.S.C. 1302, 3301, 3304, 3328 & 8716
Optional Form 306 Revised August 2023
Previous editions obsolete and unusable
General Information
1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)
2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)
3b. ARE YOU A U.S. CITIZEN?
YES NO (If "NO", provide country of citizenship)
4. DATE OF BIRTH (MM / DD / YYYY)
5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.) 6. PHONE NUMBERS (Include area codes)
Day
Night
Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.
7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)
7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)
7c. If "NO," describe your reason(s) in item 16.
(*This form may also be used to assess fitness for federal contract employment)
Military Service
8. Have you ever served in the United States military? YES (If "YES", provide information below) NO
If your only active duty was training in the Reserves or National Guard, answer "NO.”
If you answered "YES," list the branch, dates, and type of discharge for all active duty.
Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge
Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.
For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .
9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?
(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.
YES NO
10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.
YES NO
11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.
YES NO
12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.
YES NO
13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.
YES NO
U.S. Office of Personnel Management
5 U.S.C. 1302, 3301, 3304, 3328 & 8716
Optional Form 306 Revised August 2023
Previous editions obsolete and unusable
(*This form may also be used to assess fitness for federal contract employment)
Additional Questions
14. Do any of your relatives work for the agency or government organization to which you are submitting this form?
(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.
YES NO
15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?
YES NO
Continuation Space / Agency Optional Questions
16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).
Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected,…
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