Attachment J.2 - AID 1420-17 Form.pdf

AID 1420-17 Page 1 of 2

OMB Control No: 0412-0520; Expiration Date: 3/31/2021

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

The Privacy Act Statement is found at the end of this form.

1. Name (Last, First, Middle)

2. Contractor’s Name

3. Employee’s Address (include ZIP code)

4. Contract Number

5. Position Under Contract

6. Proposed Salary

7. Duration of Assignment

8. Telephone Number (include area code)

9. Place of Birth

10. Citizenship (If non-U.S. citizen, give visa status)

11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment

12. EDUCATION (include all college or university degrees) 13. LANGUAGE PROFICIENCY (see Instruction on Page 2)

NAME AND LOCATION OF INSTITUTION MAJOR DEGREE DATE LANGUAGE

Proficiency Speaking

Proficiency Reading

14. EMPLOYMENT HISTORY (List last three (3) positions held by the individual)

POSITION TITLE

EMPLOYER’S NAME AND ADDRESS

POINT OF CONTACT &TELEPHONE #

Dates of Employment (M/D/Y)

From To

15. SPECIFIC CONSULTANT SERVICES (give last three (3) years). Continue on a separate sheet of paper, if required, to provide this information.

SERVICES PERFORMED

EMPLOYER’S NAME AND ADDRESS

POINT OF CONTACT &TELEPHONE #

Dates of Employment (M/D/Y)

From To

16. RATIONALE FOR PROPOSED SALARY (Provide the basis for the salary proposed in Block 6 with supporting rationale for the market value of the position. Continue on a separate sheet of paper, if required) Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions, consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.

17. CERTIFICATION: To the best of my knowledge, the above facts as stated are true and correct.

Signature of Employee Date

18. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)

Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information in this form. Contractor understands that USAID may rely on the accuracy of such information in negotiating and reimbursing personnel under this contract. Certifications that are false, fictitious, or fraudulent, or that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration all the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.

Signature of Contractor’s Representative Date

AID 1420-17 Page 2 of 2

INSTRUCTION

Indicate your language proficiency in block 13 using the following numeric Interagency Language Roundtable levels (Foreign Service Institute Levels). Also, the following provides brief descriptions of proficiency levels 2, 3, 4, and 5. “S” indicates speaking ability and “R” indicates reading ability. For more in-depth description of the levels refer to ADS 438

2. Limited working proficiency

S Able to satisfy routine special demands and limited work requirements.

R Sufficient comprehension to read simple, authentic written material in a form equivalent to usual printing or typescript on familiar subjects within familiar contexts.

3. General professional proficiency

S Able to speak the language with sufficient structural accuracy and vocabulary to participate effectively in most formal and informal conversations on practical, social, and professional topics.

R Able to read within a normal range of speed and with almost complete comprehension of a variety of authentic prose material on unfamiliar subjects.

4. Advanced professional proficiency

S Able to use the language fluently and accurately on all levels normally pertinent to professional needs.

R Able to read fluently and accurately all styles and forms of the language pertinent to professional needs.

5. Functionally native proficiency

S Speaking proficiency is functionally equivalent to that of a highly articulate well-educated native speaker and reflects the cultural standards of a country where the language is natively spoken.

R Reading proficiency is functionally equivalent to that of the well-educated native reader.

PAPERWORK REDUCTION ACT INFORMATION

The information requested by this form is necessary for prudent management and administration of public funds under USAID contracts. The information helps USAID estimate logistic support and allowances, the educational information provides an indication of qualifications, and the proposed salary, along with the basis and rationale for the market value is used to monitor cost and help determine reasonableness of proposed salary.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average thirty minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

United States Agency for International Development Bureau for Management

Office of Acquisition and Assistance Policy Division (M/OAA/P)

Washington, DC 20523-7100;

and

Office of Management and Budget Paperwork Reduction Project (0412-0520) Washington, DC 20503

PRIVACY ACT STATEMENT

Authority: Foreign Assistance Act, Pub. L. 87-165, as amended; and 48 CFR Ch. 7 - AIDAR, Purpose: To collect, use, maintain, and disclose information to determine the qualifications of an individual for a specific contract position and to determine the reasonableness of proposed salary or consultant rate for the services proposed under the contract.

Routine Uses: The personal information is used by USAID to maintain administrative records and to perform other administrative functions inherent in the administration of the contract. This information will be used by USAID Contracting Officers and will not be disclosed outside USAID.

Disclosure: Contractor employees/consultants under USAID cost-reimbursement contracts must submit personal, employment history, and educational data, and the contractor must provide the basis and rationale for the proposed salary as specified in the form. Providing personal information is voluntary. However, failure to provide any of the requested information may delay or prevent approval of the individual proposed under the specific contract.