Support Documents.pdf

Appendix_H- : Business Associate Agreement

I. Authority:

Pursuant to 45 C.F.R. § 164.502(e), the Indian Health Service (IHS), as a covered entity, is required to enter into an agreement with a “business associate,” as defined by 45 C.F.R. § 160.103, under which the business associate must agree to appropriately safeguard Protected Health Information (PHI) that it will use and disclose when performing functions, activities or services pursuant to its contract with the IHS. By signing Contract No. (Contract), agrees that it is a Business Associate and will comply with the terms below, in addition to other applicable Contract terms and conditions, and applicable law, relating to the safekeeping, use, and disclosure of PHI. This Appendix comprises the Business Associate Agreement (Agreement).

II. Definitions:

The following terms shall have the same meaning as those terms in 45 C.F.R. Part 160 and Part 164, which are the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended: Breach, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, PHI, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured PHI, and Use.

A. Business Associate. “Business Associate” shall generally have the same meaning as the term “business associate” at 45 C.F.R. § 160.103, and in reference to the party to this Agreement shall mean .

B. Covered Entity. “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 C.F.R. § 160.103, and in reference to the party to this Agreement, shall mean the IHS.

C. HIPAA Rules. “HIPAA Rules” shall mean the Privacy, Security, Breach

Notification, and Enforcement Rules at 45 C.F.R. Part 160 and Part 164.

D. Master Patient Index (MPI). The “Master Patient Index” or “MPI” is composed of a unique list of patients and a current list of medical centers where each patient has been seen. This enables the sharing of patient data between operationally and regionally diverse systems. Each record (or index entry) on the MPI contains a small amount of patient data used to identify individual entries.

The mission of the MPI is to uniquely identify a patient and to “link” that patient’s data throughout the IHS facilities using the Integration Control Number (ICN).

The MPI is the authoritative source of a patient’s ICN, the enterprise-wide identifier for IHS facilities and the key to accessing a patient’s record. The

Appendix : Business Associate Agreement accuracy of patient information and patient identification directly affects clinical, administrative, billing, and interdepartmental processes.

III. Obligations and Activities of Business Associate:

A. Compliance: Business Associate agrees not use or disclose PHI other than as authorized by the Agreement or as required by law. Business Associate acknowledges that it is directly liable under the HIPAA Rules and subject to civil and, in some cases, criminal penalties for making uses and disclosures of PHI that are not authorized by the Agreement or required by law. Business Associate agrees that it will require all of its agents, employees, subsidiaries, and affiliates, to whom Business Associate provides PHI, or who create or receive PHI on behalf of Business Associate for Covered Entity, to comply with the HIPAA Rules and to enter into written agreements with Business Associate that provide the same restrictions, terms, and conditions as set forth in the Agreement.

B. Subcontractors: In accordance with 45 C.F.R. §§ 164.502(e)(1)(ii) and 164.308(b)(2), which govern relations with subcontractors, Business Associate agrees to ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of Business Associate agree to the same restrictions, terms, and conditions that apply to Business Associate with respect to such PHI.

C. Safeguarding PHI: Business Associate shall develop and use appropriate procedural, physical, and electronic safeguards to protect against the use or disclosure of PHI in a manner not authorized by this Agreement or required by law. Business Associate will limit any use, disclosure, or request for use or disclosure of PHI to the minimum amount necessary to accomplish the intended purpose of the use, disclosure, or request.

D. Safeguarding Electronic PHI: Business Associate agrees to use appropriate safeguards, as set forth in Subpart C of 45 C.F.R. Part 164 with respect to electronic PHI, to prevent use or disclosure of electronic PHI other than as authorized by this Agreement or required by law.

E. Reporting Use or Disclosures Not Authorized By this Agreement or Required by Law: Business Associate agrees to report to Covered Entity any use or disclosure of PHI not authorized by this Agreement or required by law within thirty (30) days of discovering the use or disclosure, or any security incident of which it becomes aware. In addition, Business Associate shall mitigate, to the extent practicable, any harmful effect that is known to Business Associate of the use, disclosure, or security incident.

F. Reporting of Breach: In accordance with the policy of the Department of Health and Human Services, Business Associate will report, within one hour of discovery, all suspected or confirmed breaches to Covered Entity.

G. Notification of Breach of Unsecured PHI: In addition to the above, Business Associate shall notify Covered Entity of a breach, as set forth in 45 C.F.R. § 164.410, of the security of any unsecured PHI that Business Associate received from, or created or received on behalf of, Covered Entity within thirty (30) calendar days after the discovery of the breach by Business Associate, its employees, officers, and/or other agents, unless notification is specifically excepted by 45 C.F.R. § 164.412.

1. Requirements of Notice. Such notice shall include, to the extent possible, the identification of each individual whose unsecured PHI has been, or is reasonably believed by Business Associate to have been, accessed, acquired, or disclosed during such breach; a brief description of the circumstances of the breach of security, including the date of the breach and the date of Business Associate’s discovery of the breach; and the type of unsecured PHI involved in the breach. Business Associate agrees to provide any other available information that Covered Entity is required to include in notification to the individual under 45 §164.404(c). In the event notification is delayed, evidence demonstrating the necessity of the delay shall accompany the notification.

H. Individual Access to PHI: Business Associate shall maintain a designated record set for each individual for whom it maintains PHI. In accordance with an individual’s right to access his or her PHI, Business Associate shall make available all PHI in the individual’s designated record set to the individual to whom that information pertains, or, upon the request of the individual, to that individual’s authorized representative, as necessary to satisfy Covered Entity’s obligations under 45 C.F.R. § 164.524. Availability to access PHI shall be made within five (5) calendar days of receipt of a valid request.

I. Accounting of Disclosures: Business Associate shall maintain records of PHI received from, or created or received on behalf of, Covered Entity and shall document subsequent uses and disclosures of such information by Business Associate. Business Associate shall, within five (5) calendar days after receiving a request from Covered Entity, provide to Covered Entity such information as Covered Entity may require to fulfill its obligations to account for disclosures of PHI pursuant to 45 C.F.R. § 164.528.

J. Amendment of PHI: Business Associate shall, within five (5) calendar days of a request by Covered Entity, make PHI available to Covered Entity for Covered Entity to fulfill its obligations under 45 C.F.R. § 164.526 to amend PHI and shall, as directed by Covered Entity, within five (5) calendar days of receipt of such direction, incorporate any amendments into PHI held by Business Associate. In addition, Business Associate shall ensure incorporation of any such amendments into PHI held by its agents or subcontractors within ten (10) days of such direction, and shall notify Covered Entity within five (5) calendar days of when those agents or subcontractors have completed the incorporation of the amendments. Business Associate shall forward to Covered Entity all requests to amend PHI that it receives directly from individuals within five (5) calendar days of its receipt of a request.

K. Carrying out Covered Entity’s Obligations: To the extent Business Associate is to carry out one or more of Covered Entity’s obligation(s) under Subpart E of 45 C.F.R. Part 164, Business Associate agrees to comply with the requirements of Subpart E that apply to Covered Entity in the performance of such obligation(s).

L. Disclosures for Verifying Compliance: Upon request, Business Associate shall permit access by the Secretary and Covered Entity during normal business hours to its facilities, books, records, accounts, and any other sources of information, including PHI and any agreements that it has with subcontractors, vendors, and/or other agents relating to the use and disclosure of PHI received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity, for purposes of determining both Business Associate’s and Covered Entity’s compliance with the HIPAA Rules.

IV. Permitted Uses and Disclosures by Business Associate:

A. Business Associate shall not use or disclose PHI except to perform functions, activities, or services on behalf of Covered Entity as provided for in the Contract, this Agreement, the HIPAA Rules, or other applicable law.

B. Business Associate agrees that it may use or disclose PHI on behalf of Covered

Entity only:

1. Upon obtaining the authorization of the individual to whom the PHI pertains;

2. For the purposes of treatment, payment or health care operations unless Covered Entity has agreed to a restriction pursuant to 45 C.F.R. § 164.520(b)(iv)(A) or 45 C.F.R. § 164.522; or

3. Without an authorization or consent, if in accordance with 45 C.F.R. § 164.510, 45 C.F.R. § 164.512, 45 C.F.R. § 164.514(e), 45 C.F.R. § 164.514(f), or 45 C.F.R. § 164.514(g).

C. Business Associate shall use and disclose PHI in compliance with each applicable requirement of 45 C.F.R. § 164.504(e), which section is fully incorporated herein.

D. Business Associate agrees to make uses, disclosures, and requests for PHI consistent with Covered Entity’s minimum necessary policies and procedures.

E. It is anticipated that Business Associate will have access to the MPI.

F. Business Associate may not use or disclose PHI in a manner that would violate Subpart E of 45 C.F.R. Part 164 if done by Covered Entity, except for the specific uses and disclosures set forth below.

1. Business Associate may disclose PHI for the proper management and administration of Business Associate or to carry out the legal responsibilities of Business Associate, provided the disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

V. Obligations of Covered Entity:

A. Covered Entity shall provide Business Associate with its Notice of Privacy Practices and any changes to the Notice.

B. Covered Entity shall notify Business Associate of any limitation(s) in Covered

Entity’s Notice of Privacy Practices under 45 C.F.R. § 164.520, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI.

C. Covered Entity shall notify Business Associate of any change in, or revocation of, the permission by an individual to use or disclose his or her PHI to the extent that such changes may affect Business Associate’s use or disclosure of PHI.

D. Covered Entity shall notify Business Associate of any restriction on the use or disclosure of PHI that Covered Entity has agreed to or is required to abide by under 45 C.F.R. § 164.522, to the extent that such restriction may affect Business Associate’s use or disclosure of PHI.

E. Covered Entity shall not request Business Associate to use or disclose PHI in any manner that would not be permissible under Subpart E of 45 C.F.R. Part 164 if done by Covered Entity, except as provided in Part IV, Subpart F, Section 1.

VI. Termination:

A. Term: The Term of this Agreement shall be effective as of the date Business Associate signs the underlying Contract and shall terminate when the Contract ends or on the date covered entity terminates for cause as authorized in paragraph

(b) of this Section, whichever is sooner.

B. Termination for Cause: Business Associate authorizes termination of this

Agreement by Covered Entity, if Covered Entity determines Business Associate has violated a material term of the Agreement and Business Associate has not ended the violation within the time specified by Covered Entity.

C. Obligations of Business Associate Upon Termination: Upon termination of this

Agreement for any reason, Business Associate, with respect to PHI received from Covered Entity, or created, maintained, or received by Business Associate on behalf of Covered Entity, shall:

1. Retain only that PHI which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities;

2. Return to Covered Entity, or, if agreed to by Covered Entity, destroy, the remaining PHI that Business Associate does not need to continue its proper management and administration or to carry out its legal responsibilities;

3. Continue to use appropriate safeguards, in compliance with Subpart C of 45 C.F.R. Part 164, with respect to electronic PHI to prevent use or disclosure of electronic PHI, other than as provided for in this Part, for as long as Business Associate retains the PHI;

4. Not use or disclose PHI retained by Business Associate other than for the purposes for which such PHI was retained and subject to the same conditions set out above, at Part IV, Subpart F, Section 1 of the Agreement which applied prior to termination;

5. Return to Covered Entity, or, if agreed to by Covered Entity, destroy, the PHI retained by Business Associate when it is no longer needed by Business Associate for its proper management and administration or to carry out its legal responsibilities; and

6. If Business Associate or its agent or subcontractor destroys any PHI, Business Associate will provide Covered Entity with documentation evidencing such destruction within thirty (30) days of completion of destruction.

D. Survival: The obligations of Business Associate under this Part shall survive the termination of this Agreement.

VII. Indemnification:

In the event Business Associate is investigated and/or becomes a party to a civil or criminal cause of action in any forum relating to its failure to comply with the HIPAA Rules, Business Associate shall reimburse Covered Entity all reasonable costs and expenses Covered Entity may incur relating to such investigation and/or cause of action, and will otherwise hold Covered Entity harmless for any and all reasonable costs and expenses relating to the foregoing.

VIII. Miscellaneous:

A. Incorporation: This Agreement is attached to and fully incorporated into the Contract.

B. Notices: All notices under this Agreement shall be provided by certified mailing, and shall require proof of date of receipt.

C. Regulatory References: A reference in this Agreement to a section in the HIPAA Rules means the section as in effect or as amended.

D. Amendment: The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for compliance with the requirements of the HIPAA Rules and any other applicable law.

E. Interpretation: Any ambiguity in this Agreement shall be interpreted to permit compliance with the HIPAA Rules.

F. Successors and Assigns: This Agreement shall be binding upon, inure to the benefit of and be enforceable by and against the Parties and their successors and assigns.

G. Severability: If a court of competent jurisdiction deems any provision of this Agreement unenforceable, such provision shall be severed from this Agreement

H. and every other provision of the Agreement shall remain in full force and effect.

CONTRACTORS PERFORMANCE CONDITIONS & RESPONSIBLITIES:

1. Contractor is responsible for reporting all taxes from wages earned under this contract to the appropriate State and Federal Agencies, provided the awardee is an individual.

2. Contractor is responsible for his/her own reliable transportation in the perfonnance of the contract.

3. Contractor is responsible for Fringe Benefits and other benefits such as health, retirement, etc., for his/her employees, if other than self.

4. Contractor is responsible for maintaining satisfactory standards of competence, conduct, appearance and integrity. The quality of work performance of the contractor shall be subject to review.

5. Contractor is responsible for notifying the designated supervisor/director if he/she will be late, ill or unable to work for other reasons,

6. Contractor earns no leave and is compensated only for hours actually worked at the agreed compensatory rate.

Contractor is responsible for signing-in and signing-out of immediate work area, utilizing in-house system of accounting.

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HHS Residual Standards of Conduct Page 1 of 4

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HHS Residual Standards of Conduct

These Standards were published in a booklet entitled "Standards of Conduct" on March 30, 1989 (45 CFR Part 73). Subsequently, HHS published the Supplemental Standards of Ethical Conduct for Employees of DHHS which covers ethics rules and regulations. Therefore, only the following subparts and sections of the HHS Standards of Conduct remain in effect. [Please consult with the Office of General Counsel prior to taking any action based on any of these subpart/sections. Revised by OGC, 5/2/2000.]

§ 73.735-301 -- Courtesy and consideration for others

§ 73.735-302 -- Support of department programs

§ 73.735-305 -- Conduct in Federal buildings

§ 73.735-306 -- Sexual harassment

§ 73.735-508(e) -- Government decisions Outside Official channels

§ 73.735-805 -- Advice and guidance on conflicts matters

Subpart L -- Disciplinary Action (§ 73.735-1201)

Subpart M -- Reporting Violations (§§ 73.735-1301 -- 73.735-1304)

Appendix to Part 73 -- List of Some Offenses for Which Disciplinary Action May be Taken

§ 73.735-301 Courtesy and consideration for others.

(a) An employee's conduct on the job is, in all respects, of concern to the Federal government. Courtesy, consideration, and promptness in dealing with the public must be shown in carrying out official responsibilities, and actions which deny the dignity of individuals or conduct which is disrespectful to others must be avoided. Employees must recognize that inattention to matters of common courtesy can adversely affect the quality of service the Department is responsible for providing. Where appropriate, courtesy to the public should be included in the standards for employee performance.

(b) Of equal importance is the requirement that courtesy be shown in day-by-day interaction with co-workers. Employees shall be polite to and considerate of other employees, and shall respect their needs and concerns in the work environment.

§ 73.735-302 Support of department programs.

(a) When a Department program is based on law, Executive Order or regulation, every employee has a positive obligation to make it function as efficiently and economically as possible and to support it as long as it is a part of recognized public policy. An employee may, therefore, properly make an address explaining and interpreting such a program, citing its achievements, defending it against uninformed or unjust criticism, or soliciting views for improving it.

(b) An employee shall not, either directly or indirectly, use appropriated funds to influence, or attempt to influence, a Member of Congress to favor or oppose legislation. However, when authorized by his or her supervisor, an employee is not prohibited from: (1) Testifying, on request, as a representative of the Department on pending legislation or proposals before Congressional Committees; or (2) Assisting Congressional Committees in drafting bills or reports on request, when it is clear that the employee is serving solely as a technical expert under the direction of committee leadership.

(c) All employees shall be familiar with regulations and published instructions that relate to their official duties and responsibilities and shall comply with those directives. This includes carrying out proper orders from officials authorized to give them.

(d) Employees are required to assist the Inspector General and other investigative officials in the performance of their duties or functions. This requirement includes the giving of statements or evidence to investigators of the Inspector General's office or other HHS investigators authorized to conduct investigations into potential violations.

§ 73.735-305 Conduct in Federal buildings.

(a) An employee shall not participate while on Government-owned or leased property or while on duty for the Government, in any gambling activity including the operation of a gambling device, in conducting a lottery or pool, in a game for money or property, or in selling or purchasing a numbers slip or ticket.

(b) An employee shall not while in or on Government-owned or leased property or while on duty for the Government solicit alms and contributions, engage in commercial soliciting and vending, display or distribute commercial advertisements, or collect private debts.

(c) The prohibitions in paragraphs (a) and (b) of this section do not preclude: (1) Activities necessitated by an employee's law enforcement duties; (2) Participation in Federally sponsored fund-raising activities conducted pursuant to Executive Order 10927, or similar HHS approved activities; or (3) Buying a lottery ticket at an authorized State lottery outlet for a lottery authorized by State law and conducted by an agency of a State within that State.

(d) General Services Administration regulations on ''Conduct on Federal Property'' apply to all property under the control of the General

HHS Residual Standards of Conduct Page 2 of 4

Services Administration, and they are also applicable to all buildings and space under the control of this Department. These regulations prohibit, among other things, gambling, being intoxicated, and possession, distribution, or use of narcotic or dangerous drugs on the premises.

The GSA regulations are found in Subpart 101-20.3 of the GSA Regulations, 41 CFR 101-20.3.

§ 73.735-306 Sexual harassment.

Sexual harassment is deliberate unsolicited verbal comments, gestures, or physical contact of a sexual nature which are unwelcome. Sexual harassment is unacceptable conduct and is expressly prohibited. In addition, supervisors and managers are prohibited from taking or promising personnel actions in exchange for sexual favors, or failing to take an action because an employee or applicant for employment, refuses to engage in sexual conduct. This same prohibition applies to relationships between Department personnel who take or recommend action on a grant or contract and the grantee or contractor. Those employees who wish to file a complaint of sexual harassment should contact the Office of Equal Employment Opportunity (EEO) within their respective agencies for guidance. (Time frames for pursuing a charge alleging sexual harassment are the same as for any other complaint based on allegations of sex discrimination.)

§ 73.735-508(e) Other prohibitions.

Employees shall avoid any action whether or not specifically prohibited by this part, which might result in or create the appearance of:

(e) Making a Government decision outside official channels

§ 73.735-805 Advice and guidance on conflicts matters.

(a) Whenever an employee has a question about the appropriate course of conduct to be followed in a matter that may involve an actual or apparent conflict of interest, he or she should immediately consult with his or her supervisor or a deputy ethics counselor, or both. If a supervisor who is consulted determines that the matter warrants further consideration, he or she may, in conjunction with the employee, submit the details of the matter, in writing, to the appropriate deputy ethics counselor. These details should include a description of:

(1) The activity, relationship, or interest giving rise to the question posed by the employee;

(2) The duties or official responsibilities of the employee(s) involved;

(3) The nature of the actual or apparent conflict of interest; and

(4) Any other information that may be helpful in reviewing the problem.

(b) Upon receiving the submission of an employee or a supervisor, the deputy ethics counselor will develop any additional information about the matter as necessary, and will confer with the Department Ethics Counselor as appropriate. The Department Ethics Counselor and the head of the principal operating component or his or her designee will be informed of any serious violation of the standards of this subpart or any other conflict of interest law. Questions of first impression or other unusual matters shall be brought to the attention of the Department Ethics Counselor and the head of the principal operating component or his or her designee.

(c) On the basis of all information gathered including, where appropriate, the advice of the Department Ethics Counselor, the deputy ethics counselor will:

(1) Decide that there is no violation or potential violation of the standards of this subpart or any other law and so notify the employee and his or her supervisor in writing; or

(2) Decide that a violation or potential violation of the standards of this subpart or other law has occurred or may occur, and that the employee involved shall take one or more of the steps set forth in § 731.735-904 to resolve the problem and notify the employee and his or her supervisor in writing; or

(3) Decide that, although no violation of this subpart or other law has occurred, the nature of the matter is such that the employee should periodically report any additional information that would require reconsideration of the initial submission.

Subpart L -- Disciplinary Action (§ 73.735-1201)

§ 73.735-1201 General provisions.

(a) Violations of the regulations con-tained in the Part may be cause for disciplinary action which could be in addition to any penalty prescribed by law. (For a list of some offenses for which disciplinary action may be taken and ''The Code of Ethics for Government Service,'' the violation of which may also result in disciplinary action, see Appendixes A and B of this Part).

(b) The type of disciplinary action to be taken must be determined in relation to the specific violation. Those responsible for recommending and for taking disciplinary action must apply judgment to each case, taking into account the general objectives of meeting any requirements of law, deterring similar offenses by the employee and other employees, and maintaining high standards of employee conduct and public confidence. Some types of disciplinary action which may be considered are:

(1) Admonishment

(2) Written reprimand

(3) Reassignment

(4) Suspension

(5) Demotion

(6) Removal

(c) Suspension, demotion, and removal are adverse actions; and when such actions are taken, applicable laws, regulations, and policies must be followed. [46 FR 7369, Jan. 23, 1981, as amended at 53 FR 4409, Feb. 16, 1988]

Subpart M--Reporting Violations

§ 73.735-1301 Responsibility for reporting possible criminal violations. An employee who has information which he or she reasonably believes indicates a possible offense against the United States by an employee of the Department, or any other individual working on behalf of the Department, shall immediately report such information to his or her supervisor, any management official, or directly to the Office of the Inspector General. Offenses covered by the preceding sentence include, but are not limited to, bribery, fraud, perjury, conflict of interest, misuse of funds, equipment, or facilities, and other conduct by a government officer or employee, grantee, contractor or other person which is prohibited by title 18 of the United States Code. Employees and supervisors should refer to chapter 5-10 of the Department's General Administration Manual for procedures regarding the reporting and handling of such information.

APPENDIX A TO PART 73--LIST OF SOME OFFENSES FOR WHICH

DISCIPLINARY ACTION MAY BE TAKEN

Following is a list of some offenses for which disciplinary action may be taken under this Part. When a statute applies specifically to a particular offense, either wholly or in part, the statute is cited. Neither the list of offenses nor the statutory citations are all-inclusive. The ''Code of Ethics for Government Service'' is not cited because of its general applicability but is published in its entirety in Appendix B.

HHS Residual Standards of Conduct Page 3 of 4

A. Concerning Efficiency of Operations in General.

1. Engaging in wasteful actions or behavior in the performance of assigned duties; conducting non-Government business during official work hours; or participating in a strike (18 U.S.C. 1918), work stoppage, slowdown, sickout, or other similar action.

2. Absence without leave, failure to adhere to the rules and regulations for requesting and obtaining leave, or improper use of sick leave.

3. Deliberate insubordination or refusal to carry out lawful orders or assignments given.

4. Disruptive behavior, such as:

a. Inflicting or threatening or attempting to inflict bodily injury on another (except for necessary defense of self or others) while on the job or on Federal premises.

b. Discourtesy, disreputable conduct, or use of insulting, abusive or obscene language to or about other individuals while on the job.

5. Sexual harassment of employees or members of the public.

6. Failure to observe precautions for safety, such as failure to use safety equipment when it is provided or ignoring signs, posted rules or regulations, or written or verbal safety instructions.

7. Unauthorized use, possession, or distribution of alcoholic beverages (5 U.S.C. 7352) or controlled substances (e.g., hallucinogens, such as LSD; stimulants, such as cocaine and amphetamines; sedatives, such as barbiturates; narcotics and other drugs or substances, such as hashish and other cannabis substances).

8. Unauthorized gambling; or canvassing, soliciting, or peddling on Government premises.

9. Failure to carry or show proper identification or credentials as required by competent authority; misuse of identification cards or investigative or identification credentials or badges.

10. Failure to disclose (i.e., report) information, when such disclosure is not specifically prohibited by law or Executive Order, that involves

(a) violation of law, rule, or regulation, (b) mismanagement or gross waste of funds or abuse of authority, or (c) posing a substantial and specific danger to public health or safety; failure to cooperate in an official Department inquiry.

11. Failure to pay just debts, including taxes to and loans from governmental sources.

12. Deceit or interference in a Civil Service examination (18 U.S.C. 1917) or in connection with a Government personnel action.

13. Fraud or false statements in a Government matter. (18 U.S.C. 1001 through 1003.)

14. Supervisory failure to initiate disciplinary or corrective action when the facts are known and disciplinary or corrective action is warranted.

15. Employment of a member of an organization that advocates the overthrow of our constitutional form of government. (5 U.S.C. 7311;

50 U.S.C. 784.)

B. Concerning Government Funds, Property, Documents, and Records.

1. Actual or attempted embezzlement or theft of Government or personal money or property either directly or through use of Government documents, automated equipment, or other means; actual or attempted embezzlement or theft of the money or property of another person in the possession of an employee by reason of his or her employment. (18 U.S.C. 641 and 654.)

2. Failure to account for public money. (18 U.S.C. 643.)

3. Deliberate falsifying of official time and attendance records; improper use of official travel or forging, counterfeiting, or otherwise falsifying official Government travel records or documents. (18 U.S.C. 508.)

4. False record entries or false reports of money or securities. (18 U.S.C. 2073.)

5. Loss or misuse of or damage to Government property or endangering persons or Government property through carelessness or by willful malicious conduct.

6. Mutilating, destroying, or concealing public records. (18 U.S.C. 2071.)

7. Misuse of penalty (postal) privilege. (18 U.S.C. 1719.)

8. Failure to safeguard administratively confidential, financial, and trade secrets information.

9. Unauthorized use of documents presented or used to procure the payment of money from or by the Government. (18 U.S.C. 285.)

10. Unauthorized use of a Government vehicle; serious or repeated violations of traffic regulations while driving a Government vehicle or a vehicle rented or leased for official Government purposes; reckless driving or improper operation of any Government owned, rented, or leased motor vehicle. (31 U.S.C. 1349[b].)

11. Violations of the Privacy Act, including:

a. Willful prohibited disclosure of individually identifiable information in violation of 5 U.S.C. 552a.

b. Willfully maintaining a system of records without meeting the notice requirements of the Privacy Act as required by 5 U.S.C.

552a.

12. Violation of regulations concerning the release of classified information, confidential, or security and investigative information. (18

U.S.C. 798 and 1905; 21 U.S.C. 331j; and 50 U.S.C. 783.)

C. Concerning Conflicts of Interest and Related Unethical Conduct:

1. Violations of 18 U.S.C. Chapter 11: Bribery, Graft, and Conflicts of Interest, including:

a. Having a direct or indirect financial interest (includes employee ownership of stocks, bonds, or partnership interests in an entity or employment of the employee, his or her spouse, or dependent child) that conflicts with one's Government duties because such entity is either regulated by, has or seeks to do business with the agency, or has any other particular matter with or pending before the agency that may give rise to either an actual conflict or the appearance thereof. (18 U.S.C. 208.)

b. Bribery of a public official; soliciting or accepting directly or indirectly anything of monetary value, including gifts, gratuities, favors, entertainment, or loans either as compensation for governmental services or from individuals who are seeking contractual or other business or financial relations with the Department, are conducting operations or activities that are regulated by the Department, or have interests that may be substantially affected by the performance or nonperformance of the employee's official duties; receiving salary or any contribution to or supplementation of salary from a private source as compensation for services for the Government. (18 U.S.C. 201 and 209.)

c. Acting as the agent of a foreign principal registered under the Foreign Agents Registration Act. (18 U.S.C. 219.)

2. Engaging, directly or indirectly, in a financial transaction as a result of or primarily relying on information that is obtained through one's official duties and would not be available were the employee not an employee of the Federal Government.

3. Soliciting a contribution from another employee for a gift to an official superior, making a donation as a gift to an official superior, or accepting a gift from an employee receiving less pay than oneself. (5 U.S.C. 7351.)

4. Engaging, without required permission, in outside activities that result in or create the appearance of a conflict of interest.

5. Teaching, lecturing, or writing that depends in specific information obtained as a result of one's Government employment when that information is not otherwise available to the public.

6. Failure to obtain required clearance of an official speech or article.

7. Lobbying with appropriated funds. (18 U.S.C. 1913.)

8. Representation before a Federal agency (other than in the proper discharge of one's official duties) as an agent or attorney in a claim against the United States (or receiving any gratuity or share in any such claim in consideration for assistance given) or as an agent or attorney for anyone before any department, agency, court, or otherwise in connection with any proceeding, application, request for a ruling, or claim on any other particular matter in which the United States is a party or has a direct and substantial interest. (18 U.S.C.

205.) (Note: This section notwithstanding, an employee may, if not in-consistent with the performance of his or her official duties, act without compensation as an agent or attorney for another person who is the subject of any disciplinary or other administrative proceeding or as an agent or attorney for one's parent, spouse, child, or any person or estate for whom or which he or she serves as personal fiduciary except in those matters in which the employee has participated personally and substantially.)

D. Concerning Prohibited Political and Election Activities.

1. Activities prohibited by 5 U.S.C. Chapter 73, Subchapter III, including:

a. Section 7323, ''Political contributions; prohibition.''

b. Section 7324, ''Influencing elections; taking part in political campaigns; prohibitions; exceptions.''

HHS Residual Standards of Conduct Page 4 of 4

2. Activities prohibited by 18 U.S.C. Chapter29, including:

a. Section 594, ''Intimidation of voters.''

b. Section 597, ''Expenditures to influence voting.''

c. Section 598, ''Coercion by means of relief appropriations.''

d. Section 600, ''Promise of employment or other benefit for political activity.''

e. Section 601, ''Deprivation of employment or other benefit for political contribution.''

f. Section 602, ''Solicitation of political contributions.''

g. Section 604, ''Solicitation from persons on relief.''

h. Section 606, ''Intimidation to secure political contributions.''

E. Concerning Prohibited Personnel Practices.

1. Commission of a prohibited personnel practice (as defined in 5 U.S.C. 2302[b] [1-11]); that is, any employee who has authority to take, direct others to take, recommend, or approve any personnel action, shall not, with respect to such authority, commit any of the following practices:

a. Discriminate for or against any employee or applicant for employment on the basis of race, color, religion, sex, national origin, age, handicapping condition, marital status, or political affiliation.

b. Solicit or consider any recommendation or statement, oral or written, with respect to any individual who requests or is under consideration for any personnel action unless such recommendation or statement is based on the personal knowledge or records of the person furnishing it and consists of (1) an evaluation of the work performance ability, aptitude, or general qualifications of such individual or (2) an evaluation of the character, loyalty, or suitability of such individual.

c. Coerce the political activity of any person (including the providing of any political contribution or service) or take any action against any employee or applicant for employment as a reprisal for the refusal of any person to engage in such political activity.

d. Deceive or willfully obstruct any person with respect to such person's right to compete for employment.

e. Influence any person to withdraw from competition for any position for the purpose of improving or injuring the prospects of any other person for employment.

f. Grant any preference or advantage not authorized by law, rule, or regulation to any employee or applicant for employment

(including defining the scope or manner of competition or the requirements for any position) for the purpose of improving or injuring the prospects of any particular person for employment.

g. Appoint, employ, promote, advance, or advocate for appointment, employment, pro-motion, or advancement, in or to a civilian position any individual who is a relative (as defined in 5 U.S.C. 3110) when the civilian position is in the Department or under his or her jurisdiction or control.

h. Take or fail to take a personnel action with respect to any employee or applicant for employment as a reprisal for the lawful disclosure of information.

i. Take or fail to take any personnel action against an employee or applicant for employment as a reprisal for the exercise of any appeal right granted by any law, rule, or regulation (including HHS Instructions and issuances).

j. Discriminate for or against any employee or applicant for employment on the basis of conduct that does not adversely affect the performance of the employee or applicant or the performance of others (except criminal conviction in determining suit-ability or fitness).

k. Take or fail to take any personnel action when the taking of or failure to take such action violates any law, rule, or regulation implementing, or directly concerning the merit system principles (as set forth in 5 U.S.C. 2301).

[53 FR 4410, Feb. 16, 1988]

Updated: 2/15/13

Updated: 2/15/13

Home Page | DECs | Ethics Offices & Staff | HHS Office of the General Counsel, Ethics Division (Intranet) | Office of Government Ethics (OGE)

Accessibility | Department of Health and Human Services (HHS) (Public site) | HHS Intranet

For information on bioethics or research ethics, please visit NIH Bioethics Resources, the NIH Office of Intramural Research (OIR) , or the NCI training on human subject protection.

For general comments or suggestions about the NIH Ethics Program website only, send email to Christy Barnett at barnettch@mail.nih.gov.

For general comments or suggestions about the NIH website, send email to mailto:nihinfo@od.nih.gov

NIH...Turning Discovery Into Health ®

EPARTMENT OF HEALTH & HUMAN SERVICES

DATE:

FROM: Ron Cornelius, Area Director

MEMORANDUM

Great Plains Area Indian Health Service Federal Building, Room 309 115 4th Ave. SE Aberdeen, SD 57401

SUBJECT: Courtesy and Respect in the Workplace Policy

TO: All Great Plains Area, Civil Service Employees, Commission Corps Officers, Contractors, Volunteers and Other Providers.

The single most important thing we can offer our patients, customers and coworkers-is courtesy and respect in our daily interactions.

No matter what your job title, grade, duties or responsibilities are, your number one job is to perform those duties and responsibilities in a manner that is consistent with the standards of conduct outlined in the Department's Standard of Conduct, Subpart C Conduct on the Job, 73.735-301 Courtesy and consideration for others. This Subpart reads as follows:

(a) An employee's conduct on the job is, in all respects, of concern to the Federal Government. Courtesy, consideration, and promptness in dealing with the public must be shown in carrying out official responsibilities, and actions which deny the dignity of individuals or conduct which is disrespectful to others must recognize that inattention to matters of common courtesy can adversely affect the quality of service the Department is responsible for providing.

(b) Ofequal importance is the requirement that courtesy is shown in daily interaction with coworkers. Employees shall be polite to and considerate of other employees and shall respect their needs and concerns in the work environment.

I expect each individual who works for the Great Plains Area IHS to adhere to these requirements. I expect each supervisor and/or manager to hold their subordinates responsible for meeting this standard and taking appropriate corrective action when individuals violate it. I also expect management to take appropriate corrective action when first line supervisors fail to exercise their supervisory responsibilities.

While I am emphasizing only one ofthe sections under Subpart C, I expect each supervisor and manager to become familiar with the entire subpart. I also expect each supervisor to assure that anyone over whom they exercise supervisory control is knowledgeable ofand adhere to all aspects ofthe Standards of Conduct. You may access a copy of the HHS Standards of Conduct by following this link:

http://ethics.od.nih.gov/lawreg/hhs-resid-std.htm#301

I am issuing this policy memorandum to demonstrate my commitment to assuring courtesy, respect and dignity in the work place. Everyone from patients, clients, customers and employees have the right to expect a professional environment when they walk through the doors of any Great Plains Area IHS facility.

This memorandum is to be distributed "desk to desk" with supervisors assuring that each employee, officer, contract and/or volunteer has knowledge of it and initials a copy of the memorandum. Chief Executive Officer and Division Directors are to assure that this memorandum is posted in appropriate places in plain sight of anyone entering their work area.

If you have questions or need assistance, you may contact the Regional Human Resource Officer, Employee/Labor Relations staff by calling (605) 226-7553.

Ron Cornelius Area Director mhtml:file://M:\AAO-DAM (Small Purchases)\Conduct & Ethics Handouts\Workplace Violence.mht 10/11/2013

Indian Health Manual (IHM) - Special General Memorandum 95-4 Page 1 of3

Special General Memorandum 95-4 ꞏ-- ...........-. -.. -ꞏ•--..- . - -ꞏꞏꞏ .. - . -ꞏꞏ•- --,-ꞏ-ꞏ- -ꞏ----- ... - -

, ,.... DEPARTMENT OF HEALTH AND HUMAN SERVICES Publio Health Service

Indian Health Service Rookv/1/e MD 20857

BGM95-4

JUN1, 1995

TO:

FROM:

SUBJECT:

Ind/an Health Service Employees Director Workplace Violence

I am fully committed to ensuring that the work environment for ell Indian Health Service (IHS) employees is healthy, safe, end secure from acts or threats of vlolenae. To accomplish this, I am establlshfng a zero tolerance policy on Workplace Violence (WPV) that appl/es equally to the behavior of all emptoyess, contractors and others with whom we work.

Our work environm9nt must b9 free from all fonns of violence and acts of Intimidation, Including haressment, threats, altercations, or assault. You are reminded that such conduct by /HS employees will not be tolerated and known Incidents should be reported Immediately to management offlolafs. I expeot all employees to act In a manner that is respeotfu/ and courteous to the public, as well as lo fellow employees.

The /HS Is not a hlgh•rfsk environment for WPV, but this Agenoy Is not Immune. Many of us work In environments where the rfsks far violence may be higher than In the traditional offlce setting. I have taken this position to heighten awareness and to assist In the prevenuon of violent Incidents st ell /HS facilities. To enforce this policy through Agenoy management omcfals, staff who commit or threaten violent acts or acts of Intimidation In the workplace will be subject to governing policies end procedures for addressing employee misconduct. In addition, If warranted, misconduct wlll be referred to local police and legal authorities for possible action.

Agency coflectlve bargaining offlc/als (CBO) must provide a copy of this memorandum tounions and meet existing bargaining unit obligations before Implementing WPV policy. I encourage CBOs to meet with existing bargaining unit representatives todevelop a strong labor-management partnership to prevent WPV.

I urgf1 you toJoin me and your co.workers In scUvely creating and supporting a work environment that Is safe, supportive, and free from WPV. These are difficult and stressful times for many of us, so awareness and early Intervention are crltlcal steps In the prevention process. If you have any questions or need assistance, please contact your local human resources staff.

/Michael Trujlllo, MD, MPH/ Michael H. Trujillo, M.D.1 M.P.H.

Assistant Surgeon General mhtml:file://M:\AAO-DAM (Small Purchases)\Conduct & Ethics Handouts\Workplace Violence.mht 10/11/2013

Indian Health Manual (IHM) .. Special General Memorandum 95-4 Page2of3

Memorandum

JUN 12, 1995

FROM:

SUBJECT:

TO:

Assistant Secretary for Health

Violence in the Workplace

PHS Agency Heads Acting Surgeon Geneml Deputy Assistant Secreter/es for Hes/th PHS Agenoy E>cecutlve Officers PHS staff Offfce Directors PHS Regional Health Administrators

Received

JUN 161995

The news mod/a remind us almost dally that we live In an environment that Is becoming lncrussfngty more violent. Many of our employees haw, been exposed to violence or threats of violence In their dally lives, and a s/gnlfloant number are concerned about the potential for violence In the workplace. For these reasons, I believe It Is lmpottant to set forth PHS po/Icy on thfs subject.

Employees shall be protected as fully as possible from assaults, threats, Intimidation, and hsrassmrmt while at the work site. Thus, It Is essential that we make clear to all PHS employess that violence, threats of Violence, Intimidating and otherwise similar dlsrupUve behavior are unacceptable conduot that will not be tolerated. This policy also applies to contractors who are not employees but who work In PHS facilities.

f.

In order ta minimize the potential for violence In the workplace and to ensure that prompt corrective action can be taken when It does ocour, anyone working In PHS facilities, who witnesses or…