OF 306.doc

APPENDIX A

OMB Approved

Form No. 0917-0028

Expiration Date: 11/30/2015

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 101-647, requires that 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, Public Law 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 that 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 PRA Information Collection Clearance Staff, 12300 Twinbrook Parkway, Suite 450, Rockville, MD 20852. Please do not send completed data collection instruments to this address.