ATTACHMENT F Permits and Forms.pdf

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10.0%

7.5%

5.0%

ON FIRST $20,000

ON NEXT $30,000

ON BALANCE OVER $50,000

3B

1C

3A

1A

(Line 6 and 7)10.0%

INSURANCE AND TAXES

OMITTED WORK

(CREDIT)

(B)

PRIME

CONTRACTOR

FEE

OTHERS (Equipment, testing, etc.)

TOTAL ► -$

LINE

NO.

1B SUBCONTRACTOR

PROPOSAL

(VA FORM 10-3385b)1D

1E

ELECTRICAL -$

SPECIAL/GENERAL/CONSTRUCTION

3C

DIRECT

OVERHEAD

(Line 8)

TOTAL DIRECT COST ► -$

NET DIRECT COST (Line 8, Col.C - Col.B) ►

TOTAL CHANGE ORDER COST (Line 4 + 14) ► -$ -$

PROFIT

TOTAL PRIME CONTRACTOR COST ► -$ -$

-$ -$ (Line 5)

TAXES ON MATERIAL AND EQUIPMENT

11A

Profit, Overhead, and Fee Calculation in accordance with VAAR 852.236.88 (Jul 2002)VA FORM 08-3385a

CONSTRUCTION CHANGE ORDER COST SUMMARY

(PRIME CONTRACTOR)

Department of Veterans Affairs

PROPOSAL REQUEST NO. VA PROCEED ORDER NO. VA CHANGE ORDER NO.

ADDED WORK

(COST)

(C)

ITEM

(A)

SITE WORK

MECHANICAL AND HVAC

PROJECT NAMEPROJECT NO.

PROJECT LOCATION

CONTRACT NO. NAME OF PRIME CONTRACTOR

DESCRIPTION OF WORK

PRIME CONTRACTOR DIRECT LABOR

PRIME CONTRACTOR DIRECT MATERIAL

PRIME CONTRACTOR EQUIPMENT RENTAL

ESTIMATOR:

11C

TOTAL SUBCONTRACTOR COST ►

11B

10A

10B

10C

PROJECT LOCATION

CONTRACT NO. NAME OF SUBCONTRACTOR

CONSTRUCTION CHANGE ORDER COST SUMMARY

(SUBCONTRACTOR)

PROJECT NO. PROJECT NAME

LINE

NO.

ITEM

(A)

OMITTED WORK

(CREDIT)

(B)

ADDED WORK

(COST)

(C)

1 DIRECT LABOR -$

DESCRIPTION OF WORK

PROPOSAL REQUEST NO. VA PROCEED ORDER NO. VA CHANGE ORDER NO.

4 TOTAL DIRECT COST ► -$ -$

5 NET DIRECT COST (Line 4, Col. C - Col. B) ► -$

2 DIRECT MATERIAL -$

3 EQUIPMENT RENTAL -$

6B ON NEXT $30,000 -$ (Line 5) -$

6A

DIRECT

OVERHEAD

ON FIRST $20,000 -$ (Line 5)

6C ON BALANCE OVER $50,000 -$ (Line 5) -$

7A

PROFIT

ON FIRST $20,000 -$ (Line 5) -$

7B

8 INSURANCE AND TAXES 10.0% (Line 1) -$ -$

ON NEXT $30,000 -$ (Line 5) -$

7C ON BALANCE OVER $50,000 -$ (Line 5)

10 TOTAL ► -$ -$

11 COST PROPOSAL (Line 10, Col C - Col B) -$

9 TAXES ON MATERIAL AND EQUIPMENT 10.0% (Lines 2 and 3) -$ -$

ESTIMATOR: S. Kang DATE

VA FORM 08-3385b Profit, Overhead, and Fee Calculation in accordance with VAAR 852.236.88 (Jul 2002)

12 CREDIT PROPOSAL (Line 10, Col B - Col C) -$

REMARKS

852.236-88 Contract changes - supplement.

As prescribed in 836.578, insert the following clause:

CONTRACT CHANGES - SUPPLEMENT (JUL 2002)

The clauses entitled “Changes” in FAR 52.243-4 and “Differing Site Conditions” in FAR 52.236-2 are supplemented as follows:

(a) Paragraphs (a)(1) through (a)(4) apply to proposed contract changes costing over $500,000.

(1) When requested by the contracting officer, the contractor shall submit proposals for changes in work to the resident engineer. Proposals, to be submitted as expeditiously as possible but within 30 calendar days after receipt of request, shall be in legible form, original and two copies, with an itemized breakdown that will include material, quantities, unit prices, labor costs (separated into trades), construction equipment, etc.

(Labor costs are to be identified with specific material placed or operation performed.) The contractor must obtain and furnish with a proposal an itemized breakdown as described above, signed by each subcontractor participating in the change regardless of tier. When certified cost or pricing data are required under FAR Subpart 15.403, the cost or pricing data shall be submitted in accordance with FAR 15.403-5.

(2) When the necessity to proceed with a change does not allow sufficient time to negotiate a modification or because of failure to reach an agreement, the contracting officer may issue a change order instructing the contractor to proceed on the basis of a tentative price based on the best estimate available at the time, with the firm price to be determined later. Furthermore, when the change order is issued, the contractor shall submit a proposal, which includes the information required by paragraph (a)(1), for cost of changes in work within 30 calendar days.

(3) The contracting officer will consider issuing a settlement by determination to the contract if the contractor's proposal required by paragraphs (a)(1) or (a)(2) of this clause is not received within 30 calendar days o if agreement has not been reached.

(4) Bond premium adjustment, consequent upon changes ordered, will be made as elsewhere specified at the time of final settlement under the contract and will not be included in the individual change.

(b) Paragraphs (b)(1) through (b)(11) apply to proposed contract changes costing $500,000 or less:

(1) When requested by the contracting officer, the contractor shall submit proposals for changes in work to the resident engineer. Proposals, to be submitted as expeditiously as possible but within 30 calendar days after receipt of request, shall be in legible form, original and two copies, with an itemized breakdown that will include material, quantities, unit prices, labor costs (separated into trades), construction equipment, etc. (Labor costs are to be identified with specific material placed or operation performed.) The contractor must obtain and furnish with a proposal an itemized breakdown as described above, signed by each subcontractor participating in the change regardless of tier. When certified cost or pricing data or information other than cost or pricing data are required under FAR 15.403, the data shall be submitted in accordance with FAR 15.403-5. No itemized breakdown will be required for proposals amounting to less than $1,000.

(2) When the necessity to proceed with a change does not allow sufficient time to negotiate a modification or because of failure to reach an agreement, the contracting officer may issue a change order instructing the contractor to proceed on the basis of a tentative price based on the best estimate available at the time, with the firm price to be determined later. Furthermore, when the change order is issued, the contractor shall submit within 30 calendar days, a proposal that includes the information required by paragraph (b)(1) for the cost of the changes in work.

(3) The contracting officer will consider issuing a settlement by determination to the contract if the contractor's proposal required by paragraphs (b)(1) or (b)(2) of this clause is not received within 30 calendar days, or if agreement has not been reached.

(4) Allowances not to exceed 10 percent each for overhead and profit for the party performing the work will be based on the value of labor, material, and use of construction equipment required to accomplish the change. As the value of the change increases, a declining scale will be used in negotiating the percentage of overhead and profit. Allowable percentages on changes will not exceed the following: 10 percent overhead and 10 percent profit on the first $20,000; 7-1/2 percent overhead and 7-1/2 percent profit on the next $30,000; 5 percent overhead and 5 percent profit on balance over $50,000. Profit shall be computed by multiplying the profit percentage by the sum of the direct costs and computed overhead costs.

(5) The prime contractor’s or upper-tier subcontractor’s fee on work performed by lower-tier subcontractors will be based on the net increased cost to the prime contractor or upper-tier subcontractor, as applicable. Allowable fee on changes will not exceed the following: 10 percent fee on the first $20,000; 7-1/2 percent fee on the next $30,000; and 5 percent fee on balance over $50,000.

(6) Not more than four percentages, none of which exceed the percentages shown above, will be allowed regardless of the number of tiers of subcontractors.

(7) Where the contractor's or subcontractor’s portion of a change involves credit items, such items must be deducted prior to adding overhead and profit for the party performing the work. The contractor’s fee is limited to the net increase to contractor of subcontractors’ portions cost computed in accordance herewith.

(8) Where a change involves credit items only, a proper measure of the amount of downward adjustment in the contract price is the reasonable cost to the contractor if he/she had performed the deleted work. A reasonable allowance for overhead and profit are properly includable as part of the downward adjustment for a deductive change. The amount of such allowance is subject to negotiation.

(9) Cost of Federal Old Age Benefit (Social Security) tax and of Worker’s Compensation and Public Liability insurance appertaining to changes are allowable. While no percentage will be allowed thereon for overhead or profit, prime contractor’s fee will be allowed on such items in subcontractors’ proposals.

(10) Overhead and contractor’s fee percentages shall be considered to include insurance other than mentioned herein, field and office supervisors and assistants, security police, use of small tools, incidental job burdens, and general home office expenses and no separate allowance will be made therefore. Assistants to office supervisors include all clerical, stenographic and general office help Incidental job burdens include, but are not necessarily limited to, office equipment and supplies, temporary toilets, telephone and conformance to OSHA requirements. Items such as, but not necessarily limited to, review and coordination, estimating and expediting relative to contract changes are associated with field and office supervision and are considered to be included in the contractor’s overhead and/or fee percentage.

(11) Bond premium adjustment, consequent upon changes ordered, will be made as elsewhere specified at the time of final settlement under the contract and will not be included in the individual change.

(End of Clause)

Contractor Background Investigation Request

VA Organization Billing Information

Upload signed request to SIC Resource Site.

Printed/Distilled Copy

Only original can be submitted to SIC.

https://dvagov.sharepoint.com/sites/LIT/vasic/default.aspx

Organization: [ ]

Station:

Station Label: Station #

Date Label: Current Date:

Date:

Organization Label: VA Organization

City Of Birth Label: City of Birth

Date of Birth Label: Date of Birth

Company POC Label: Company POC

Company POC Email Label: POC Email Address

Company City Label: City

Company Zip Label: Zip

Last Name:

Middle Name:

Company State: [ ]

First Name:

Company State Label: State

Last Name Label: Last Name

Middle Name Label: Middle Name

First Name Label: First Name

SSN Label: SSN

SSN:

Gender:

Gender Label: Gender

Email Address:

Country of Citizenship: [ ]

Country Of Birth Label: Country of Birth

State of Birth Label: State of Birth

Email Address Label: Email Address

Country of Citizenship Label: Country of Citizenship

Position Title Label: Position Title

Company POC:

Position Title:

Priority Label: Priority

Child Care Label: Child Care

Priority: Off

Child Care: Off

Individual Information Label: Individual Information

Company Information Label: Company Information

COR Information: CO / COR

COR Name Label: Name of CO / COR

State of Birth: [ ]

Company Zip:

Company City:

Company POC Email: Use semicolons for multiple addresses.

COR Name:

Options Label: Additional options may be presented after an investigation is selected.

Investigation Label: Investigation

Investigation: [Select One...]

Contractor Company Label: Contractor Company

Contractor Company:

Task Order Number Label: Task Order Number

Task Order Number:

POC Address Label: POC Address

POC Address:

Phone Number Label: Phone Number

Phone Number:

Reinvestigation Label: Reinvestigation

Reinvestigation: Off

Include SAC Label: Include SAC

Include SAC: Off

Country of Birth: [ ]

State Instructions: Leave blank if foreign born.

City of Birth:

Date of Birth:

COR Email Label: CO / COR Email

COR Email: Use semicolons for multiple addresses.

Location:

Location Label: Location

Signature Label: Signature

Notes: Additional Notes

FINGERPRINT RECORD

PREP SHEET

Circle one: YOUR Employment Status below Applicant Current Employee Volunteer Contractor Renewal (PIV) Student WOC Resident Fellow Fee Basis Background (INV)

____ COURTESY SON: _______ SOI: __________

____ Unclassifiable (HR Staff ONLY) ________________________

FULL NAME

(LAST, FIRST MIDDLE)

FULL Social Security Number (SS#)

DOB -

Month/Date/Year

ALIAS (other names used) If none, write NONE

SEX

RACE – (if applicable, specify ETHNICITY)

EYE COLOR

HAIR COLOR

HEIGHT

(FT/IN)

WEIGHT

(LBS)

PLACE OF BIRTH

(STATE / COUNTRY)

COUNTRY OF

CITIZENSHIP

SERVICE OR DEPT.

(within the VA)

POSITION - Title (within the VA)

PHONE NUMBER

(where we can reach you)

E-MAIL ADDRESS

(VA or personal)

HOME ADDRESS

Signature of Person being Fingerprinted:_______________________________________________ Please have ready 1 (one) form of current photo ID HR Staff ONLY

DATE PRINTED: __________ PRINTED/COMPLETED BY:________________________

Revised 4/23/2015 (HR Security Staff ONLY)

PLEASE PRINT CLEARLY

Assignment over 180 days (circle one)

Yes No

Providing Direct Patient Services (circle one)

CITY

STREET

STATE ZIP CODE

DEPARTMENT OF VETERANS AFFAIRS

PERSONNEL SECURITY ADJUDICATION CENTER

Self Certification of Continuous Service

I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than two (2) years. (You are required to submit the OF 306, Declaration for Federal

Employment, with this form.)

My break in service is greater than two (2) years; or I have never had federal employment as defined above.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

(Check One)

Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee (any federal government agency), or a contractor working for the federal government.

Self Certification of Continuous Service Form Revised February 28, 2020

Previous Versions are Obsolete

I have NOT had a break in service: Off

My break in service was less than 60 days: Off

My break in service was greater than 60 days but less than 2: Off

My break in service is greater than 2 years or I have never worked: Off

Print Name:

Social Security Number:

Date:

Current Investigation in PIPS:

Date_2:

Risk level of current position:

Verified by:

VA Greater Los Angeles Healthcare System Interim Life Safety Measures Assessment

See ILSM requirements at the end of this document before completing this form (ILSM Is Good For the Duration of Construction)

To be filled out by the contractor prior to start of Construction and provided to COR

Date: ________________________ Facility: __________________________Project Name: _______________________

Start Date: _____________ Superintendant: ___________________________ Phone Number: _____________________

Project Location: _______________________________________________Project Number: _______________________

Description of work to be performed:

Use the following criteria to determine appropriate Interim Life Safety Measures (ILSM) for your project. (See the end of this document for a description of ILSM requirements).

1. Will all exits be free from obstructions?

Yes. No further action required. No. Post conspicuous signs directing occupants to alternate exit. Distribute notices to occupants advising them of designated exit.

**Does the hospital post signage identifying the location of alternate exits to everyone affected?

2. Will the fire alarm system remain in good working order?

Yes. No further action required. No. A fire watch must be implemented. Fill out a fire watch implementation form and submit to security for execution.

**Does the hospital notify the fire department (or other emergency response group) and initiate a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building?

3. Will the fire-suppression systems (sprinklers) remain in good working order?

Yes. No further action required. No. A fire watch must be implemented. Fill out a fire watch implementation form and submit to security for execution.

**Does the hospital notify the fire department (or other emergency response group) and initiate a fire watch when a fire alarm or sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building?

4. Will temporary construction barriers be used in this project?

Yes. Must be built smoke-tight and constructed of noncombustible, or limited combustible materials.

No. No further action required.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital use temporary construction partitions that are smoke tight, or made of vhaglasubhan

Rectangle noncombustible material, or made of limited-combustible material that will not contribute to the development or spread of fire?

5. Will additional portable fire extinguishers be provided?

Yes. No further action required. No. Obtain a spare 10-lb. ABC fire extinguisher and place in conspicuous location in project area.

**The contractor shall provide fire extinguishers (10 lbs ABC) in the construction site. The extinguishers shall be properly mounted and checked monthly.

6. Will packaging, debris, and discarded materials be removed daily to minimize combustible loads?

Yes. No further action required. No. STOP! All discarded material must be removed daily to minimize combustible loads.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital enforce storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level?

7. Will additional fire drills be required in affected areas, due to change in exiting or other impairments?

Yes. Notify safety officer for implementation. No. No further action required.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital conduct one additional fire drill per shift per quarter?

8. Will increase hazard surveillance of the project area be conducted daily by the project manager?

Yes. No further action required. No. STOP! The project manager must perform increased hazard surveillance of the project area on a daily basis.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices?

10. Will building occupants need to be trained to compensate for impaired Life Safety features?

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital provide additional training to those who work in the hospital on the use of fire-fighting equipment?

11. Will an organization-wide safety education program be required to promote awareness of hazards?

**Does the hospital conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety?

12. Will temporary systems be tested or inspected on a monthly basis?

Yes. No further action required. No. STOP! Temporary systems must be tested or inspected monthly.

N/A (No systems will be affected)

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital inspect and test temporary systems monthly? Is the completion date of these tests documented?

ILSM Assessment Completed By (PRINT): __________________________________________________

Signature: _______________________________________ Date: ___________________________________

Description of Interim Life Safety Measures to be Implemented

Based on the responses to the evaluation questions, provide a description of the Interim Life Safety measures that will be implemented during the project to compensate for the deficiency or condition.

Project COTR Date

Contractor or M&O Representative Date

Safety Officer or Designee Date

ILSM Requirements ILSM are a series of eleven administrative actions required to be taken to temporarily compensate for the hazards posed by existing LSC deficiencies or construction activities.

(1) Ensure exits provide free and unobstructed egress. Employees shall receive training if alternative exits must be designed.

(2) Ensure free and unobstructed access to emergency department and for emergency forces.

(3) Ensure fire alarm, detection, and suppression systems are not impaired. A temporary, but equivalent, system shall be provided when any fire system is impaired. Temporary systems must be inspected and tested monthly. (4) Ensure temporary construction partitions are smoked tight and built of noncombustible materials.

(5) Provide additional firefighting equipment and use training for employees within affected area.

(6) Smoking shall be prohibited in or adjacent to all construction areas within the healthcare system.

(7) All storage in areas that are sprinklered shall be kept 18" inches below the sprinkler head. There will be no storage of any type in halls, passageways, or walkways.

(8) All empty boxes, trash, and waste will be properly disposed of in approved waste storage bins provided by Environmental Management Department. All work areas shall be kept clean and free of debris and unnecessary flammable materials at all times.

(9) Additional fire drills will be conducted in the areas affected by ILSMs until the ILSMs are rescinded.

(10) Increase hazard surveillance in the area affected by ILSMs until the ILSMs are rescinded.

(11) Training will be provided to all employees in the area affected by ILSMs to ensure that these employees understand the ILSMs and that the new fire/emergency procedures that have been implemented.

ILSM Educational Awareness Worksheet (Contractor to coordinate time and date with COR)

Notification for staff in areas affected by ILSM implementation.

(to be filled out by contractor)

Date: _______________

Building/Floor/Locations of Notification: _______________________________________________

Location of Construction: ________________________________________________________

Type of ILSM’s implemented: ________________________________________________________

Content

Overview

Notification for all employees who are affected by Interim Life Safety Measures.

Objectives After completing the training, employees will be able to recognize and understand interim life safety measure to be determined.

Scenario Fire Alarm and/or Sprinkler System disabled: Employees were re-oriented on the fire procedures and the location of the fire apparatus. Operator will be contacted using the phone and dialing “12” (WLA), “3” (Sepulveda) “2222” (LAACC), if alarm is disabled. All employees had the emergency numbers given to them.

BLOCKING OFF AN APPROVED EXIT: Employees were oriented on the alternative exit(s), reference attached drawings, pictures and/or layouts.

Educational

Awareness

a. Personnel/Patients/Visitors adhere to temporary construction and/or Interim Life Safety Measure signs posted.

b. Re-orientate employees on the proper evaluation routes in their immediate work areas.

c. Enforce good storage and housekeeping practices.

d. Ensure Exits maintain clear and unobstructed at all time.

e. Prohibit smoking.

Problems to

Watch For

a. Corridor and exit routes obstructed

b. Smoking

c. Dust and dir ty corr idors from construction workers

Orientation On a. Special Precautions, Signs, PPE, etc.

b. Temporary partitions, re-routing of exits.

Service/Departments: ______________________________________________________

Employees Notified:

(Fill out names of all employees attending training and/or receiving notification)

1. __________________________ 16. ____________________________

2. __________________________ 17. ____________________________

3. __________________________ 18. ____________________________

4. __________________________ 19. ____________________________

5. __________________________ 20. ____________________________

6. __________________________ 21. ____________________________

7. __________________________ 22. ____________________________

8. __________________________ 23. ____________________________

9. __________________________ 24. ____________________________

10. __________________________ 25. ____________________________

11. __________________________ 26. ____________________________

12. __________________________ 27. ____________________________

13. __________________________ 28. ____________________________

14. __________________________ 29. ____________________________

15. __________________________ 30. ____________________________

Name of Instructor Date

(Contractor or COR)

Date:

Facility:

Project Name:

Start Date:

Superintendant:

Phone Number:

Project Location:

Project Number:

Description of work to be performed 1:

undefined_3:

undefined_5:

undefined_6:

undefined_8:

undefined_9:

undefined_10:

undefined_12: Off undefined_14:

undefined_15:

undefined_17:

undefined_18:

undefined_19:

undefined_20: Off undefined_22:

undefined_23:

undefined_24:

undefined_25: Off undefined_26:

undefined_27: Off undefined_29:

undefined_30: Off undefined_31:

ILSM Assessment Completed By PRINT:

Date_2:

that will be implemented during the project to compensate for the deficiency or condition 1:

Project COTR:

Date_3:

Contractor or MO Representative:

Date_4:

Safety Officer or Designee:

Date_5:

Date_6:

BuildingFloorLocations of Notification:

1_2:

Location of Construction:

Type of ILSMs implemented:

1_3:

ServiceDepartments 1:

ServiceDepartments 2:

1_4:

Name of Instructor:

Date_7:

X:

16:

AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)

STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE

I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.

The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.

VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.

I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.

SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED

OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)

CURRENT ADDRESS (Include Street, City, State, and ZIP Code)

VA FORM

OCT 2017 0710

..\logos\VA Form Bar-04(NEW LOGO).jpg

AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)

AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 16 81)

STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE

Statement of Authorization and Clarification of Purpose

I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.

The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.

VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.

I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.

I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.

The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.

VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.

I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.

SIGNATURE OF EMPLOYEE (Sign in ink)

TYPE OR PRINT LEGIBLY FULL NAME

DATE SIGNED

OTHER NAMES USED

HOME TELEPHONE NUMBER (Include Area Code)

CURRENT ADDRESS (Include Street, City, State, and ZIP Code)

VA FORM

OCT 2017

V A Form 0 7 1 0, OCTOBER 2017

VA Form 0710, AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)

0710, Authorization, Release, Information, Protected, Fair, Credit, Reporting, Act

Missie Vaccaro-Palomaki

MAY 1998

OCTOBER 2017

Trish Moore

(07)

Signature of Employee Sign in ink:

TYPE OR PRINT LEGIBLY FULL NAME:

DATE SIGNED:

OTHER NAMES USED:

HOME TELEPHONE NUMBER (Include Area Code):

CURRENT ADDRESS (Include Street, City, State, and ZIP Code):

TEST AND INSPECTION REQUEST

A.

B.

Test Required by (name of contractor)

Date of Inspection Request

Date of Inspection Required

Date of Inspection Completed

Inspector’s Name

C.

Test/ Inspection Requested:

Choose an item.

Drawing Page/ Detail:

Inspector Comments, Exception and/or Approvals

Re-inspection required:

If Yes, describe re-inspection requirement

YES NO

I hereby declare under penalty of perjury that all above statements are true and to the best of my personal knowledge the work herein described by this report has been performed and installed in compliance with the approved plans, specifications and all applicable codes and standards.

Inspector/ Certified Person Signature Date

Facility Name

Project #

Project Title

Project Location (bldg. & rm #)

Facility Name:

Project:

Project Title:

Project Location bldg rm:

Test Required by name of contractor:

Date of Inspection Request:

Date of Inspection Required:

Date of Inspection Completed:

Inspectors Name:

Test Inspection Requested Choose an item:

Drawing Page DetailInspector Comments Exception andor Approvals:

Reinspection required If Yes describe reinspection requirement:

Text28:

Check Box29: Off

Check Box30: Off

Text31:

Text32:

Declaration for Federal Employment* (*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 2011

Previous editions obsolete and unusable

Instructions

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. 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. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement

Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

GENERAL INFORMATION

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

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

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc)

6. PHONE NUMBERS (Include area codes)

Day ♦ Night ♦

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Are you a male born 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.

Military Service

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

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

If your only active duty was training in the Reserves or National Guard, answer "NO."

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law,mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES," use item 16 to provide the relative's name,relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

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?

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any attached sheets. When this form and all attached materials are accurate, read item 17, and complete 17a.

APPOINTEE: If you are being appointed, 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. I certify 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 . I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent 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. I understand 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 (Sign in ink)

17b. Appointee's Signature: Date (Sign in ink)

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

18. Appointee (Only respond if you have been employed by the Federal Government before): 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? DATE:

MM / DD / YYYY

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

YES NO DO NOT KNOW

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

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 2011

Previous editions obsolete and unusable

Optional Form 306 (Rev. October 2011)

Declaration for Federal Employment (This form may also be used to assess fitness for federal contract employment)

U.S. Office of Personnel Management

Instructions

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. 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. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11"). Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other…