Contractor Forms.pdf

Mandatory Seasonal Influenza Immunizations for Civilian Health Care Personnel

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Indian Health Service

Rockville, Maryland 20857

Refer to: OPHS

INDIAN HEALTH SERVICE CIRCULAR NO. 2016-04

Effective Date: July 28, 2016

MANDATORY SEASONAL INFLUENZA IMMUNIZATIONS FOR THE CIVILIAN HEALTH

CARE PERSONNEL

Sec.

1. Purpose

2. Background

3. Policy

4. Definitions

5. Procedures

6. Compliance

6. Supersedure

7. Effective Date

1. Purpose. This circular establishes the Indian Health Service (IHS) policy requiring mandatory seasonal influenza immunizations for civilian health care personnel working in IHS health care facilities.

2. Background. Influenza vaccination for health care facility staff and licensed independent practitioners is a major patient safety issue in the United States and is an important component of comprehensive infection control programs. Individuals who become infected are contagious at least one day before any signs or symptoms of influenza appear, and therefore these individuals can infect others without knowing they are contagious.

3. Policy. All Civil Service employees, contract staff, temporary employees, students, and volunteers who work in an IHS health care facility, must receive a seasonal influenza vaccination by October 31 of each year or have on file a valid medical or religious exemption. The vaccination deadline may be extended if seasonal influenza vaccine supply is inadequate or sufficiently protracted to preclude timely vaccination. Commissioned Corps Officers of the United States Public Health Service (PHS) are already required to obtain their annual seasonal influenza immunization (per Manual Circular - Commissioned Corps Personnel - PHS No. 377, Subchapter CC26.1 Instruction 8, PHS Readiness Standards).

4. Definitions.

A. Health Care Personnel. All Civil Service employees, contract staff, temporary employees, students, and volunteers whose duties and responsibilities require them to work permanently, temporarily or occasionally in an IHS health care facility are considered Health Care Personnel (HCP) for the purposes of this policy, regardless of their job category or level of patient contact.

B. Health Care Facility. Any Federal IHS hospital, clinic, or health station.

5. Procedures.

A. Documentation. All HCP must provide acceptable documentation substantiating influenza vaccine receipt or request for exemption within 2 calendar weeks following issuance of this circular and by Oct. 31 annually in subsequent years. Personnel routinely charged with infection control and/or employee health responsibilities at the facility are responsible for maintaining records of employee vaccination, medical exemption, or religious exemption as part of the employee health record.

Receipt of Influenza Vaccine

a. Influenza Vaccine Administered Within IHS Facilities. Influenza vaccine will be offered free of charge to all HCP working in IHS health care facilities every influenza season. At the time of vaccination, the following information should be recorded in the employee health record: the date of administration, vaccine formulation (i.e., brand), vaccine manufacturer, dose volume, anatomic site of administration, vaccine lot and expiration date, and name of the provider administering the vaccine. Upon request, employees may be provided written documentation of the influenza vaccination.

b. Influenza Vaccine Administered Outside IHS Facilities. Any HCP who receive influenza vaccine elsewhere must provide written proof of vaccination that documents the date of vaccination, vaccine formulation (i.e., brand), and name of provider administering the vaccine. This information will be filed along with any additional documentary proof of vaccination as part of the employee health record.

Request for Exemption

a. Medical Exemption from Influenza Vaccination. A request for medical exemption from influenza vaccination may be approved for any person contraindicated to receive influenza vaccine as outlined by Advisory Committee on Immunization Practices (ACIP) recommendations (see link below). (http://www.cdc.gov/flu/professionals/vaccination/index.htm ) Based on current recommendations, valid medical exemptions for influenza vaccines include a history of severe allergic reaction to any component of the influenza vaccine, including egg protein, or serious allergic reaction to a previous dose of influenza vaccine. History of Guillain-Barré Syndrome (GBS) onset within 6 weeks following a prior influenza vaccine is a precaution for influenza vaccination, and may be considered a valid medical exemption if a medical provider determines the influenza vaccination poses a risk to the patient.

i. Procedure for requesting a medical exemption. All HCP requesting medical exemption from influenza vaccination must provide documentation, signed by a licensed, independent health care practitioner, affirming that a valid medical contraindication exists that precludes influenza vaccination. Personnel routinely charged with infection control and/or employee health responsibilities at the facility will be designated to receive, review, approve/deny medical exemption requests in accordance with current ACIP recommendations, and maintain suitable records to document requests and outcomes. Employees whose request for medical exemption is denied will receive written justification for the denial and must receive influenza vaccination within 2 calendar weeks of the denial notification.

ii. Renewal. Employees with an approved medical exemption must provide a signed statement by October 31st annually reaffirming that the previously approved medical contraindication continues to preclude vaccination. Such statements and other supporting documentation (e.g., statement from employee's medical provider) will be retained as part of the employee's health record.

b. Religious Exemption from Influenza Vaccination. Any HCP who feel their religious beliefs preclude influenza immunization may request an exemption from influenza vaccination.

Procedure for requesting religious exemption. Any HCP who feel their religious beliefs preclude influenza immunization must submit a signed, written statement justifying the request by October 31st annually for review. Personnel routinely charged with infection control and/or employee http://www.cdc.gov/flu/professionals/vaccination/index.htm https://www.ihs.gov/Disclaimers

6. Compliance. Health care personnel who refuse to comply with this policy and do not have an approved medical or religious exemption are subject to disciplinary action in accordance with Department of Health and Human Services and/or IHS policy and relevant sections of collective bargaining agreements as applicable. Employee refusal to comply with this policy will be documented and filed as part of the employee health record.

7. Supersedure. This circular supersedes IHS SGM 2015-03, dated September 3, 2015.

8. Effective Date. This circular becomes effective on the date of signature.

/Mary Smith/ Mary Smith

Principal Deputy Director Indian Health Service

Distributed: IHS-wide Date: July 28, 2016 health responsibilities at the facility will be designated to receive, review, approve/deny requests for religious exemption, and maintain suitable records to document requests and outcomes. Supporting statements and approval of religious exemption requests from influenza vaccination will be maintained as part of the employee health record.

c. Appeal of denials.

i. Medical exemption requests. Review and adjudication of appeals will be conducted by the facility Clinical Director or Service Unit Chief Medical officer. Secondary appeals can be made to the Area Chief Medical Officer. Third and final level of appeals can be made to the IHS Chief Medical Officer or their designee.

ii. Religious exemption requests. Review and adjudication of appeals will be conducted by the facility's Chief Executive Officer. Secondary appeals can be made to the Area Director. Third and final level of appeals can be made to the IHS Chief Medical Officer or their designee.

Approved Exemption. Unvaccinated HCP with an approved medical or religious exemption must wear an IHS-provided surgical or similar mask when working in patient care areas or other areas frequented by patients in an IHS health care facility during the influenza season. Influenza season is typically defined as November through March, though may include other periods of increased levels of influenza activity as determined by the Centers for Disease Control and Prevention and/or state public health authorities. All HCP with an approved medical or religious exemption are required to receive annual instruction from appropriate infection control staff at the facility on the proper use of masks and other infection control measures relevant for preventing influenza infection.

Form Approved:

OMB No. 3206-0182 Declaration for Federal Employment*

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

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. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. 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.

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

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. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

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

Military Service

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

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

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

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.

YES NO

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.

YES NO

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

YES NO

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.

YES NO

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.

YES NO

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

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

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 relativeworks.

YES NO

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

YES NO

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

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:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(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

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

OMB Approved Form No. 0917-0028 Expiration Date: 04/30/2025

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.

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