Contractor Forms.pdf

Addendum to Declaration for Federal Employment (OF 306) Indian Health Service

Child Care & Indian Child Care Worker Positions Item 15a. Agency Specific Questions

Name: ___________________________ Social Security Number: __________________ (Please print)

Job Title in Announcement: ____________________ Announcement Number: ___________

Section 231 of the Crime Control Act 1990, Public Law 101-647, requires that employment applications for Federal child care positions 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.

Section 408 of the Miscellaneous Indian Legislation, 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.

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 AYES@, 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 AYES@, 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 fines of up to $2,000 or 5 years imprisonment, 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 15 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.

FORM APPROVED: O.M.B. NO. 0917-0028 Expires 09/30/2012

April 19, 2011

RFQ-11-175 _RC-2PAorNPs

II. Department of Health and Human Services Acquisition Regulations (HHSAR) (49 Chapter 3) Clauses