P01. Self Certification Form.pdf
PDF 887 KB Posted
- Attached to
- S201--Housekeeping Aide Services - NWI
- Solicitation number
- 36C26325Q0386
About this file
This is a Self Certification of Continuous Service form from the Department of Veterans Affairs WMC-HROO Personnel Security Contractor Processing Team, revised June 16, 2022. The form requires contractors to certify their break in federal service status by selecting one of four options: no break in service, break less than 60 days, break between 60 days and 2 years (requiring OF 306 form submission), or break greater than 2 years/never had federal employment.
The form defines federal employment as service in any U.S. military branch (Active, Guard, or Reserve), federal government civilian employment, or work as a contractor/sub-contractor for the federal government. It includes fields for the individual's printed name, social security number, signature, and date, along with a section for VHA Personnel Security/HR use to document current investigation status in PIPS, risk level assessment, and verification details. This document appears to be part of the contractor processing requirements for a housekeeping aide services solicitation at the VA Nebraska Western Iowa Health Care System.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| S02. RFQ 36C26325Q0386.pdf | ||
| P01. Process for PIV.pdf | ||
| P01. OF 306 Example.pdf | ||
| P07. WD 2015-5005 - Omaha.pdf | ||
| P01. VA Privacy Training for Personnel without Access TMS 20939 FY2023.pdf | ||
| 36C26325Q0386_1.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Department of Veterans Affairs WMC-HROO Personnel Security Contractor Processing Team
Self Certification of Continuous Service
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:
VHA 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 or sub-contractor working for the federal government.
Self Certification of Continuous Service Form Revised June 16, 2022
Previous Versions are Obsolete
I hereby certify my break in service from my last federal employment is indicated by the block checked above.
EXAMPLE
| 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: |
File details come from the government source that posted it. Updated .