Attachment_2_-_Personnel_Qualifications_Sheet.doc

FA5270-18-Q-B110

IT CSSR

Attachment 2- PQS

PERSONNEL QUALIFICATIONS SHEET (PQS) – IT CSSR

1. Every item on the Personal Qualifications Sheet must be addressed. Please sign and date where indicated. Any additional information required may be provided on a separate sheet of paper (indicate by number and section the question(s) to be addressed).

2. After contract award, the information provided may be verified during the credentialing process. If you submit false information, the following actions may occur:

3. Personal and Practice Information:

Yes No

1. Have you ever been the subject of a malpractice claim? ___ ___

(indicate final disposition of case in comments)

2. Have you ever been a defendant in a felony or misdemeanor case? ___ ___

(indicate final disposition of case in comments)

3. Has your license to practice or DEA certification ever been revoked ___ ___ or restricted in any state?

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

5. a. Are you a U.S. Citizen?

b. If yes, do you hold dual citizenship or a passport from a foreign country? ___

If answered “yes” to any questions under Personal and Practice Information Section above, you will need to attach a detailed explanation. Specifically address the disposition of the claim or charges for numbers 1 through 4, and the State of the revocation for number 3 above. If you hold a dual citizenship or have a passport issued from a foreign country, address which country the dual citizenship is held and/or which foreign country has issued you a passport.

PRIVACY ACT STATEMENT

Under 5 U.S.C. 552a and Executive Order 9397, the information provided on this page and the Personal Qualifications Sheet is requested for use in the consideration of a contract; disclosure of the information is voluntary; failure to provide information will result in the denial of the opportunity to enter into a contract.

_________________________ _____________(mm/dd/yy)

(Employee Signature) (Date)

I. General Information Name: SSN:______________

Last First Middle

Date of Birth: ___________

Address: ___________________________________

Phone: ( ) ________________ Email: ________________________

Medical Information

YES NO

1. Do you have any physical or mental impairment that could limit your clinical practice?

2. Have you been hospitalized for any reason during the past 5 years?

3. Are you currently receiving or have you ever received formal mental health therapy or treatment?

4. Are you currently receiving, or have you in the past ever received, treatment or therapy for any alcohol or drug-related condition?

5. Have you ever been unlawfully involved in the use of controlled substances?

If answered “yes” to any questions under Medical Information, you will need to attach a detailed explanation.

II. State Professional Licensure (License must be current, valid, and unrestricted):

________ (State) Date of Expiration: _____________ (mm/dd/yy)

________ (State) Date of Expiration: _____________ (mm/dd/yy)

________ (State) Date of Expiration: _____________ (mm/dd/yy)

III. Board Certification(s):

Title of Certification Date of Certification (mm/dd/yy)

Title of Certification Date of Certification (mm/dd/yy)

IV. Professional Employment: List your current and preceding employers. Provide dates as month/year.

Name and Address of Present Employer From To

(1) _______________________________________________________

Superviosr’s Name:

E-mail

Phone

From To

(2) _______________________________________________________

(3) _______________________________________________________

(4) _______________________________________________________

Are you are currently employed on a contract (public or private)? If so where is your current contract and what is the position? ___________________________________________

When does the contract expire? _____________________________________ V. I am currently certified in BLS or will be certified in BLS prior to contract start-date.

YES_____________ NO _____________

VI. I am currently certified in ACLS or will be certified in ACLS prior to contract start-date.

YES_____________ NO _____________

VII. Continuing Education Hours within the preceding 3 years:

Title of Course From To CE Hours

I hereby certify the above information to be true and accurate:

(mm/dd/yy)

(Employee Signature) (Date)

Enclosures:

Copy of Professional Education Degree(s)

Copy of all medical licenses held within the preceding 10 years Copy of relevant continuing education certificates (see VIII above) Copy of two (2) Professional Recommendations

Employee Name (Printed) Note:

*Use of AMRDEC SAFE is an alternate site to send submittals and allow encryption of Personal Identifiable Information (PII). https://safe.amrdec.army.mil/safe/

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