Attachment 0002.pdf

ATTACHMENT 0002

PERSONAL QUALIFICATIONS SHEET –– PSYCHOLOGIST/PSYCHIATRIST

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. The information you provide will be used to determine your acceptability. In addition to the Personal

Qualifications Sheet, please submit two letters of recommendation as described in this attachment.

3. After contract award, all of the information you provide will be verified during the review process. At that time, you will be required to provide the following documentation verifying your qualifications:

Professional Education, Professional Registration, Experience, Personal and Professional Information

Sheet, continuing education certificates, and employment eligibly documentation. If you submit false information, this contract may be terminated for default. This action may initiate the suspension and debarment process, which could result in the determination that you are no longer eligible for future

Government contracts.

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 Has your license or certification to practice ever been revoked or ___ ___ restricted in any state?

If any of the above is answered "yes" attach a detailed explanation. Specifically address the disposition of the claim or charges for numbers 1 and 2 above, and the State of the revocation for number 3 above.

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 may result in the denial of the opportunity to enter into a contract.

(mm/dd/yy)

(Signature) (Date)

PERSONAL QUALIFICATIONS STATEMENT – PSYCHOLOGIST/PSYCHIATRIST

1. General Information

Last Name, First, MI: _________________________________________________

Address: ___________________________________________________________

Phone: (_____) ________-_________

2. Professional Education and Training (most recent first)

Basic Qualifying Degree (e.g., BS, AD, MS, MD, DO, OD, MSW, or PhD)

Institution Address From To

3. Qualifying and/or specialty Certifications

Certification Number Agency Issue Date Expires

4. List all Licenses or Certificates by State or Federal Agency. Include all those that have been either voluntarily or involuntarily withdrawn (include Drug Enforcement Agency (DEA) certification).

(License must be current, valid, and unrestricted)

__________(State) Date of Expiration: __________________ (mm/dd/yy)

5. List familiarity with the DSM-IV and psychological testing (such as WAIS-R, WISC-C, Rorschach, TAT, CAT, MMPI, MCMI, MAPI, Bender and DAP), etc.

6. Health Status and History. (Answer "yes" or "no." Explain all "yes" answers in comments section).

____ a. Do you currently have any physical or mental impairments that could limit your clinical practice?

____ b. Are you currently taking any medications?

____ c. Do you have a potentially-communicable disease?

____ d. Have you been hospitalized for any reason during the last 5 years?

____ e. Have you ever been psychiatrically hospitalized or diagnosed with a major psychiatric disorder?

____ f. Are you currently under or have you ever received treatment for an alcohol or drug-related condition?

____ g. Have you ever been involved in the unlawful use of controlled substances?

Comments: ______________________________________________________

7. Professional Employment: List your current and preceding employers. Experience as an Obstetrics &

Gynecology Physician of at least 12 consecutive months immediately preceding contract start. Provide dates as month/year. (Section D, Item 3).

Name and Address of Present Employer From To

(1)

Work Performed:

Names and Addresses of Preceding Employers

From To (2)

Work Performed:

From To (3)

8. Other information. (Include any additional information you wish to provide.)

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

(Signature) (Date)