Appendix M_IHS Contract Qualification Pre-Clearance Documents.pdf

Appendix M:

IHS Contract Qualification Pre-Clearance Documents

National COVID-19 Critical Care Response Teams (CCRT) Indefinite Delivery/ Indefinite Quantity (IDIQ) Contract

1. List of Approved Identity Source Documents (Page 2)

2. IHS Emergency/Disaster Privilege Pre‐Application Checklist; and Statement of

Understanding and Release (Pages 3-5)

3. IHS National COVID-19 Critical Care Response Teams (CCRTs) IDIQ Statement of

Understanding and Release of Information (Page 6)

4. OMB Form 0917-0028: Addendum to Declaration for Federal Employment (OF 306)

Indian Health Service Child Care & Indian Child Care Worker Positions (Pages 7-8)

5. Declaration for Federal Employment (OF-306) (IHS will provide to Contractor)

6. HHS 745: HHS Badge Request (09/2018) (IHS will provide to Contractor)

7. IHS Provisional Authorization -Pending Favorable Adjudicated Background

Investigation Memorandum (IHS will provide to Contractor)

In addition to the above forms, current resume/cv, and copies of licenses and certifications, additional documents may be required to on-board contract health care provider CCRT candidates under this contract.

The primary identity source document shall be neither expired nor canceled, must be one of the following forms of identification:

The secondary identity source document may be from the list of primary identify sources, but cannot be of the same type as the primary identity source document. The secondary identity source document may also be any of the following:

U.S. Passport or a U.S. Passport Card Permanent Resident Card or Alien Registration

Receipt Card (Form I-551) Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

Employment Authorization document that contains a photograph (Form I-766)

Driver's license or an ID card issued by a state or possession of the United States provided it contains a photograph

U.S. Military ID card U.S. Military dependent's ID card Department of Defense Common Access Card Unexpired HSPD -12 PIV ID

U.S. Social Security Card issued by the Social Security Administration

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

ID card issued by a Federal, state, or local government agency or entity, provided it contains a photograph

Voter's registration card U.S. Coast Guard Merchant Mariner card Certificate of U.S. Citizenship (Form N-560 or N-561) Certificate of Naturalization (Form N-550 or N-570) U.S. Citizen ID Card (Form I-197) ID Card for use of Resident Citizen in the United States

(Form I-179) Certification of Birth Abroad or Certification of Report of Birth issued by the Department of State (Form FS-545 or Form DS- 1350)

Unexpired Temporary Resident Card (Form I-688) Unexpired Employment Authorization Card (Form I-688A) Unexpired Reentry Permit (Form I-327) Unexpired Refugee Travel Document (Form I-571) Unexpired employment authorization document issued by

Department of Homeland Security (DHS) Unexpired Employment Authorization Document issued by

DHS with photograph (Form I-688B) Driver's license issued by a Canadian government entity Native American tribal document

Note: Departments and agencies may choose to accept only a subset of the identity source documents listed above.

For example, if the primary source document is a foreign passport (e.g., Italy), the secondary source document should not be another foreign passport (e.g., France). Also, if the name on a birth certificate that is being used for badging is different from the name on the photo ID of the applicant, an additional court document showing the name change must be provided.

IHS requires one document from Column A and one document from Column B.

National Institute of Standards and Technology, Federal Information Processing Standards Publication "Personal Identity Verification (PIV) of Federal Employees and Contractors" (FIPS PUB 201-2)

List of Approved Identity Source Documents

Indian Health Service (IHS) Emergency/Disaster Privilege Pre‐Application Checklist

Last Name ________________________ First Name ________________________ Middle Name __________________

Degree __________________ Other Name Used/Maiden Name ______________________ NPI # __________________

Primary Specialty ___________________________________ Sub‐Specialty ____________________________________

Identification Type: __________________________ ID # _____________________ Expiration Date ________________

Primary Office Address, City, State, Zip __________________________________________________________________

Primary Office Phone with Area Code ____________________________ Email _________________________________

Current Affiliation Address, City, State, Zip _______________________________________________________________

Affiliation Dates: From _______________ To _______________ Position _____________________________________

Please list all state where you have held a medical license, both active and inactive:

State – License # ‐ Expiration Date State – License # ‐ Expiration Date State – License # ‐ Expiration Date

State – License # ‐ Expiration Date State – License # ‐ Expiration Date State – License # ‐ Expiration Date

State – License # ‐ Expiration Date State – License # ‐ Expiration Date State – License # ‐ Expiration Date

DEA License # __________________ Exp ___________ State CDS License # (If Applicable) ______________ Exp _________

Specialty in which emergency/disaster privileges are desired:

Anesthesiology Radiology Pediatrics Family Medicine

Dentistry/Oral Surgery Ophthalmology Psychiatry Urgent Care

Internal Medicine Emergency Medicine Pathology OB/GYN

Surgery Podiatry Other (Please Enter):

Peer and Affiliation Reference: Name of current hospital or medical staff member(s) who possess personal knowledge regarding applicant’s ability to act as a licensed independent practitioner during a disaster:

Peer Name ___________________________________ Degree __________________ Specialty ____________________

Phone w/Area Code _____________________________ Email ______________________________________________

Current Affiliation _________________________________ Location __________________________________________

Phone w/Area Code _____________________________ Email ______________________________________________

Supervisor’s Name __________________________________ Contact Info _____________________________________

Indian Health Service (IHS) Emergency/Disaster Privilege Pre‐Application Checklist

Professional Liability Insurance Carrier

Name of Carrier _____________________________________________________________________________________

Policy # _____________________________ Dates of Coverage ______________________________________________

Emergency Contact

Name _____________________________________________ Phone w/Area Code ______________________________

During this emergency I agree to provide professional services that are within the scope of my education, licensure, and expertise in a manner consistent with standards, policies and practices of my profession. I understand and acknowledge that any privileges applied for, and granted, will be for the duration of the present emergency and shall terminate automatically when the state of emergency ends. The privileges shall be terminated immediately if I have misrepresented or withheld any information required by this pre‐application checklist or subsequent information required by the individual facility. Privileges may be denied or terminated at any time at the discretion of the person who has direct oversight. Denial or termination of disaster privileges, regardless of the circumstances, shall not give rise to the right for a hearing, review or appeal under the respective medical staff bylaws or any other standard, regulation or law.

Date Print Applicant Name Applicant’s Signature

Required Documents: The following documents will need to be supplied for application, and may need to also be presented in person at the facility for verification.

Completed and Signed Pre‐Application Checklist

Signed Statement of Understanding and Release

Government Issues Photo Identification (Present at facility upon arrival)

Any Additional Documents/Information Requested By Specific Facility

Indian Health Service

Statement of Understanding and Release

I authorize the Indian Health Service (IHS) and its representatives to inquire of any individual or entity with whom or which I have been associated (including medical malpractice carriers) who or which it deems relevant in its assessment of my professional competence, character and ethical qualifications.

This includes any information otherwise protected from disclosure by the Privacy Act, 5 United States Code (U.S.C.) 552a, et seq. and/or the Health Insurance Portability and Accountability Act of 1996, Public Law 104‐191. This authorization includes copying and inspecting any documentation (including but not limited to any general medical records, behavioral health records and substance abuse treatment records), which the IHS and its representatives deem relevant.

I consent to the disclosure by the IHS and its representatives of any information regarding my professional services at any IHS facility to any individual or entity to whom or which I subsequently apply for clinical privileges, membership, or licensure. Additionally, I release the IHS from any liability for providing such information in response to any inquiry made by any IHS employee to another IHS employee.

I release from any sort of liability the United States, the IHS, any of their representatives, and any third parties from whom or which is obtained either information or documentation for the above purposes.

I understand that I have the right to review information received about me from any outside primary source except references or recommendations that are peer review protected. In the event that the information obtained from outside primary sources varies substantially from the information I have provided, I am aware that I have the right to review and correct, if necessary, the information obtained.

Upon request, I agree to appear for purposes of responding to questions relating to any record, document or information obtained pursuant to the foregoing paragraph. I understand that my refusal to so appear may constitute cause for future denial of clinical privileges and/or appointment to any medical staff or other healthcare position for the

IHS.

All information submitted by me in this application is true and correct to the best of my knowledge. I understand that any intentional misstatement in or omission from this application may constitute cause for denial of appointment or summary dismissal from the clinical staff, at the sole discretion of the deciding entity. I agree that in either of these events, I waive all rights of recourse and damages against the United States, the IHS, and its representatives.

Applicant’s Signature Date

IHS National COVID-19 Critical Care Response Teams (CCRTs) IDIQ Statement of Understanding and Release of Information

I authorize the Indian Health Service (IHS) and its representatives to disclose any documentation submitted by me, or my representatives, to any authorized IHS, Tribal, or Urban facility utilizing my services through the IHS National COVID-19 CCRT Contract.

Contract Number: ___________________________________________

This authorization shall stay in effect for the duration of said contract.

This authorization includes copying, inspecting, and distributing any documentation (including but not limited to any applications, forms, qualification records, verification documents, or any other information otherwise protected from disclosure by the Privacy Act, 5 United States Code (U.S.C.) 552a, et seq. and/or the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191), which the IHS and its representatives deem relevant for the purpose of completing applicant review and selection, as well as, security, human resources, credentialing and privileging requirements.

All documentation submitted by me is true and correct to the best of my knowledge. I understand that any intentional misstatement in or omission from this documentation may constitute cause for denial of appointment or summary dismissal from the clinical staff, at the sole discretion of the deciding entity.

I have been provided a copy of this statement.

Print Name

Signature

Date

OMB Approved Form No. 0917-0028 Expiration Date: 12/31/2018

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.