Required Forms.pdf

To:

Subject:

New Hire and Supervisor of position covered by Public Law 101-630 Provisional Authorization- pending favorably adjudicated background investigation

This serves as notice to the supervisor and new hire/contractor/volunteer/affiliate that they will be performing work and/or occupying a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act. An individual employed/working or being considered for employment (Federal, contractor, volunteer, or affiliate) at the Indian Health Service with duties and responsibilities involving regular contact with or control over Indian children must undergo a background investigation. Prior to the receipt of a favorably adjudicated background investigation, the individual will have provisional status. At all times whenever Indian children are in the care, custody, and/or control of an individual in a provisional status, the individual is required to be under the supervision and in sight of a staff person who has a favorably adjudicated background investigation that includes child care coverage.

The following individual has been granted provisional authorization for the identified position, which has been designated as a position covered by P.L. 101-630:

Name: _________________________________ Position title: ____________________________ The following conditions must be met for the individual:

Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

Continued processing of background investigation – Tier 1 with child care (minimum).

Provide requested documentation/information as requested from the Personnel Security/HR Office.

Supervisor must ensure that new hires/contractors/affiliates who are in a provisional status and have Indian children in their care, custody, and/or control, are within the sight and supervision of a staff person who has a favorably adjudicated background investigation that includes child care coverage.

Supervisors are required to sign indicating your acceptance, responsibility, and compliance with the above criteria, and will ensure that the above named individual is assigned to appropriate personnel whenever Indian children are in their care, custody, and/or control. Failure to comply with the above criteria can result in disciplinary action, up to and including removal.

Department Supervisor/Designee Date

The facility/service unit is required to work with the Area Personnel Security/HR Office designee to maintain a list of staff members who have a favorably adjudicated background investigation with child care coverage on file for supervisors to identify and assign personnel to provide coverage to individuals in a provisional status.

I have verified that I have worked with the facility/service unit to ensure that a list of favorably adjudicated staff members is available for the supervisor’s use.

Personnel Security Representative/HR Designee Date

This provisional authorization is in effect until the favorably adjudicated certification of investigation is in place. I am aware that failure to comply with the above criteria could result in disciplinary action, up to and including removal/termination.

Employee/Contractor/Affiliate Date

1 / 2018

Indian Health Service Office of Human Resources

This form may also be used to assess fitness for federal contract employment

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

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. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, 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.

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.

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 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.

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

(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)

(Include city and state or country)

YES NO (If "NO", provide country of citizenship)

(MM / DD / YYYY)

(For example, maiden name, nickname, etc.) (Include area codes)

Day

Night

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.

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

MM/DD/YYYY) MM/DD/YYYY)

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 (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.)

10. Have you been convicted by a military court-martial in the past 7 years?

11. Are you currently under charges for any violation of law?

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?

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.)

YES NO

YES NO

YES NO

YES NO

YES NO

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

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.)

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

YES NO

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

If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith.

that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government.

that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? D

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

YES NO DO NOT KNOW

Enter Date of Appointment or Conversion

MM / DD / YYYY

OMB Approved Form No. 0917-0028 Expiration Date:

Addendum to Declaration for Federal Employment (OF 306) Indian Health Service

Child Care & Indian Child Care Worker Positions Item 16. Agency Specific Questions

Name: ___________________________ Social Security Number: __________________ (Please print)

Job Title in Announcement: ____________________ Announcement Number: ___________

Section 231 of the Crime Control Act of 1990, Public Law (Pub. L.) 101-647, requires employment applications for individuals seeking employment in a position involved with the provision to children under the age of 18 of “child care services,” as defined in 42 U.S.C. § 13041(a)(2), contain a question asking whether the individual has ever been arrested for or charged with a crime involving a child and for the disposition of the arrest or charge.

Under 42 U.S.C. § 13041(a)(2), the term "child care services" means child protective services (including the investigation of child abuse and neglect reports), social services, health and mental health care, child (day) care, education (whether or not directly involved in teaching), foster care, residential care, recreational or rehabilitative programs, and detention, correctional, or treatment services. Individuals hired for such positions must undergo a criminal history background check.

Section 408 of the Indian Child Protection and Family Violence Prevention Act, Pub. L. 101-630, contains a related requirement for positions in the Department of Health and Human Services that involve regular contact with or control over Indian children. The agency must ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes. The law requires the agency conduct an investigation of the character of each individual who is being considered for employment in such a position and prescribe in regulations the “minimum standards of character” that must be met in order for an individual to fill such a position. The regulations specify that “[t]he minimum standards of character shall be considered met only after the individual has been the subject of a satisfactory background investigation,” which includes a criminal history background check.

42 C.F.R. § 136.406.

To assure compliance with the above laws, the following questions are added to the Declaration for Federal Employment:

1. Have you ever been arrested for or charged with a crime involving a child?

YES_____ NO______

[If “YES”, provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name and address of the police department or court involved.]

2. Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to, any felonious or misdemeanor offense under Federal, State, or tribal law involving crimes of violence; sexual assault, molestation, exploitation, contact or prostitution; or crimes against persons; or offenses committed against children?

YES______ NO______

[If “YES”, provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name address of the police department or court involved.]

I certify that (1) my response to these questions is made under penalty of perjury, which is punishable by fine under title 18 of the U.S. Code, or imprisonment of not more than five years, or both; and (2) I have received notice that a criminal check will be conducted. I understand my right to obtain a copy of any criminal history report made available to the Indian Health Service and my right to challenge the accuracy and completeness of any information contained in the report.

Applicant’s Signature (sign in ink) Date

Public Burden Statement: In accordance with Paperwork Reduction Act [5 CFR § 1320.8 (b)(3)], a Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Respondents must be informed (on the reporting instrument, in instructions, or in a cover letter) the reasons for which the information will be collected; the way the information will be used to further the proper performance of the functions of the agency;

whether responses to the collection of the information are voluntary, required to obtain a benefit (citing authority), or mandatory (citing authority); and the nature and extent of confidentiality to be provided, if any (citing authority). Public reporting burden for this collection of information is estimated to average 12 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information to the IHS Information Collection Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Rockville, Mail Stop 09E70, MD 20857. Please do not send completed data collection instruments to this address.