Contractor_Forms_to_Fill_out_(2).pdf

(PLEASE COMPLETE AND RETURN)

LICENSURE REQUIREMENT

PERSONAL AND NONPERSONAL SER VICES CONTRACTORS SHALL BE SUBJECT TO THE SAME

QUALITY ASSURANCE, CREDENTIALS, LI CENSURE, AND OTHER QUALIFICATION STANDARDS

AS THOSE REQUIRED OF JHS PERSONNEL. IN ADDITION, HEALTH CARE PROVIDERS, OTHER

THAN PROFESSIONALS, MUST BE LICENSED IN A STATE, THE DISTRICT OF COLUMBIA, PUERTO

RICO, OR A TERRITORY OF THE UNITED STATES TO PERFORM THE CONTRACT SERVICES

WITHIN lHS FACILITIES. THE CONTRACTING OFFICER WILL INSERT THE FOLLOWING

CERTIFICATION STATEMENT IN ALL PURCHASE ORDERS AND CONTRACTS FOR

PROFESSIONAL MEDICAL SERVICES:

MY LICENSE TO PRACTICE 0 HAS 0 HAS NOT BEEN TERMINATED, SUSPENDED, OR

REVOKED JN ANY STA TE, THE DISTRICT OF COLUMBIA, PUERTO RICO, OR A TERRITORY OF

THE U.S ..

I CURRENTLY HOLD AN ACTIVE MEDICAL LICENSE IN THE FOLLOWING ST A TE(S):

STATE LICENSURE NO. ISSUE DATE

I HA VE AN INACTIVE MEDICAL LICENSE IN THE FOLLOWING ST A TE(S):

STATE LICENSURE NO. ISSUE DATE

I HEREBY CERTIFY THAT THE PURPOSES OF APPLICATION OF THE FALSE STATEMENTS

PROVISIONS OF THE PROGRAM FRAUD CIVIL REMEDIES ACT OF I 986 (45 CFR 79), THAT TO THE

BEST OF MY KNOWLEDGE, EACH OF THE ABOVE STATEMENTS IS TRUE, ACCURATE, AND

DOES NOT OMIT ANY MATERIAL FACT THAT WOULD RENDER THE STATEMENT FALSE,

FICTITIOUS, FRAUDULENT AS A RESULT OF TI-IE OMISSION.

SIGNATURE OF PRACTITIONER DATE

AGREEMENT TO A TEMPORARY WAIVER OF CHARACTER

INVESTIGATION (FOR GOVERNMENT EMPLOYEES, CONTRACTORS,

STUDENTS AND VOLUNTEERS)

Per your request, the Northern Plains Region of the Indian Health Service (Aberdeen, Bemidji and Billings Area Offices) has agreed to a temporary waiver of the character investigation for

(Name of employee, volunteer, student, contractor)

This temporary waiver has been agreed to with the understanding that you will continue the process of accomplishing the character investigation in accordance with Public Law 101-630, Indian Child Protection and Family Violence Prevention Act and Public Law 101-647, Crime Control Act.

The agreement is in effect until the signed certificate of investigation is received by the HSPD- 12/Security Office. I understand that in accordance with Section 231 of the Crime Control Act of 1990 (P.L. 101-647 and P.L. 101-630), that failure to comply with these statues could result in my immediate removal.

Your signature indicates you are taking the responsibility to assure Human Resources and/or the Chief of the Contracting Office, and the HSPD-12/Security Office that the above named individual will not have unmonitored contact with Indian children.

I hereby assure that such continuous monitoring will occur when said individual is in contact with Indian Children under the age of 18 years. I am aware, and will assure, that those providing DIRECT SIGHT MONITORING shall at a minimum, have had a successfully completed CNACI.

I certify that the permanent federal employees assigned to provide DIRECT SITE MONITORING has met the requirements of Section 231 of the Crime Control Act of 1990 (P .L. 101-630)

SIGNATURE OF INDIVIDUAL RESPONSIBLE

FOR DIRECT SIGHT MONITORING

CHIEF EXCUTIVE OFFICER

DATE

DATE

Declaration for Federal Employment* ('This form may also be used lo assess fitness for federal contract employmenl) fOtrn APl"OVO<l OMBNo. ~182

Instructions--------------------------------

The information cc:>llected on this fo"!' is_ used to determine your acceptability for Federal and Federal contract employment and your enrollment status m the Governments Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instr:uctions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or Imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11 ').

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement ---------------------------- The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of tiUe 5, U. S. Code. Section 1104 of tiUe 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms. this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number {SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify Individuals in agency records. Giving us your SSN or any other information Is voluntary. However, If you do not give us your SSN or any other Information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or Information In this record is in accordance with routine uses found In System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of Information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials In litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies In connection with hiring or retaining, security clearance, security or suitabillty investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits: public and private organizations, Including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospectlve non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically Identified Individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement --------------------------- Public burden reporting for this collection of lnformallon is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of Information. Send comments regarding the burden estimate or any other aspect of the collection of Information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager {3206--0182), Washington, DC 20415-7900. The OMB number, 3206--0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management $U.S.C. \302. 3301, 3304. 3328& 8710

OptioMI Form 3011 Rol'lsed Otlabet 2011

Proo.tous odilfons -· ond IAIS4l>lo

('This form may also be used to assess fitness for federal contract employmcnl)

Form f\;)p<Ovi::d.

OMO No. ~200-0102

GENERAL INFORMATION .

'd th d • d'cate "lnilial only" If you do not have a middle name. 1. FULL NAME (Provide your full name. If you have only Initials in your name. pr~v1 e . em an in 1 · indicale "No Middle Name". lfyou arc a "Jr .. " "Sr.," clc. enter !his under Suffix. First, M1ddiCl, Last, Suffix)

2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

n YES L i NO (tr"NO", provide country or clUzenship) +

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc)

Selective Service Registration

4. DATE OF BIRTH (MM/DD/YYYY)

6. PHONE NUMBERS (Include area codes)

Day + Night +

If you are a male born after December 31 , 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Are you a male born after December 31, 19597 C YES L. NO (If ''NO", proceed lo 8.)

7b. Have you registered with the Selective Service Syslem? I J YES (If "YES", proceed to 8.) C: NO (If "NO", proceed to 7c.)

7c. If "NO," describe ypur reason(s) in item 16.

Military Service

8. Have you ever served in the United Slates military? D YES (If "YES", provide Information below) r · NO ff you answered "YES," list the branch, dales, and type of discharge for all active duty.

If youfofl.lfac/ive duly was lrainirig in the Reserves or National Guard, answer: "NO.•

Background Information

For .all questions, provide all additional requested Information under Item 16 or on attached sheets. The circumstances of each event you list will be ,considered. However, in most cases you can still be considered for Federal jobs, For questions 9, 10, and 11, your answers should include convictions resulling from a plea of nolo conlendere (no contest}, but omil (1) traffic fines of $300 or less, (2) any viofaUon of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in.juvenile court or under a Youth Offender law, (4) any conviclion set aside under the Federal Youth Corrections Act or similar state law, and (5} any convictioh for which the record was expunged under Federal or stale law.

9, During the last 7 years, have you been convicled, been imprisoned, been on probation, or been on parole? r : YES I ! NO (Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses,) If "YES,• use item 16 lo provide the dale, explanation of 1110 violation, place of occurrence, and the name and address oflhe police department or court involved.

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES,• use if em 16 lo provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If •yes,• use item 16 /o provide the date, explanation of tl1e violation, plac13 of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES, " use item 16 lo provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, Joans. overpayment of benell\s, and other debts to the U.S. Government. plus defaulls of Federally guaranteed or insured loans such as .student and home mortgage loans.) If "YES,· use item 16 to provide tho type, length, and amount of 1/10 delmquenpyor default, and steps that you are laking to correct tile error or repay the debt.

r 1 1 n

YES 0 NO

YES C; NO

YES n NO

YES C NO

U.S. Office of Personnel Management

5 US.C, 1302, 3301, 3304, 3328 8. 8716

Optionol ronn ~C>3 Rc-,isad Oc:obcr 2011

Previous editions obsolete and unu5.'.lbfa rll11s fonn may also be used to assess fitness for federal conlract employment)

AddHlonal Questions

1'<11111~ OMS NO. 320EMl182

14. Do any of your relatives worl< for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, slater, uncle, aunt, first cousin, nephew, niece, I: YES r NO falher-ln-law,mother-ln-law, son-In-law, daughter-In-law, brolher-ln·law, sister-In-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepslster, half brother, and half sister.) If "YES,• use item 16 to p/OVfde the telat/va's name,tel8tionshlp, and the dopartment agency, or branch of the Anned Forces for which your relstlw worlcs.

15. Do you receive, or have you ever appfied for, retirement pay, pension, or other retired pay based on military, r YES I". NO Federal civilian, or Dlstrfct of Columbia Government service? ' 1 .. !

Continuation Space I Agency Optional Questions ------------------·

16. Provide detalls requested In Items 7 through 15 and 18c In the space below or on attached sheets. Be sure to Identify attached sheets with your name, Social Seasrity Number, and item number, and to Include ZIP Codes In all addresses. If any questions are printed below, please answer as Instructed (these questions are specific to your position and your agency Is authorized to ask them).

Certifications I Additional Questions APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any attached sheets. When this form and an attached materials are accurate, read Item 17, and complete 17a.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, Including any other appUcatlon materials that your agency has attached to this fonn. If any infonnation requires correction to be accurate as of the date you are signing, make changes on this fonn or the attachments and/or provide updated lnfonnation on additional sheets, lnitia6ng and dating all changes and additions.

When this fonn and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the lnfonnatlon on and attached to this Declaration for Federal Employment, Including any attached appllcaUon materials, is true, correct, complete, and made In good faith • I understand that a false or fraudulent answer to any question or Item on any part of this declaration or Its attachments may be grounds for not hiring me, orforflrlng me after I begin work, and may be punishable by fine or Imprisonment. I understand that any Information I give may be Investigated for purposes of determining eUglblrrty for Federal employment as allowed by law or PresfdenUel order. I consent to the release of Information about my abllity and fitness for Federal employment by employers, schools, law enforcement agencies, and other lncflViduals and organizations to Investigators, personnel speciafists, and olher authorized employees or representaUves of the Federal Govemmenl I understand that for financial or !ending Institutions, medical Institutions, hospitals, heaHh care professionals, and some other sources of ""- Information, a separate specific release may be needed, and I may be contacted for such a release at a later date •

17a. Applicanrs Signature: .,.,,.,.__,...,....,..,..-------------- Date ----- (Sign In Ink)

17b. Appointee's Signature:~-....~...-------------- Date ----- (Sign In Ink)

Appointing Officer:

Enler Diie cl~ orCcnwnlan

MM/DD/YVYY

18. Appointee (Only respond If you have been employed by the Federal Government before): Your elections of life Insurance during previous Federal employment may affect your ellgfblllty for life lnStJrance during your new appolntmenl These questions are asked to help your personnel office make a correct determination.

188. When dfd you leave your last Federal job?

18b. When you worked for the Federal Government the last time, dfd you waive Basic Life Insurance or any type of optional llfe Insurance?

MM/00/YYYY

DATE:

r YES r NO

18c. If you answered-YES• to Item 18b, did you later cancel the walver(s)? If your answer to Item n YES 1Bcls "NO,• use Item 16 to ldenUfythe type(s) of Insurance for which waivers were not · r NO canceled.

U.S. Office of Personnel Management a u.s.c. 1»2. 3301, 3304. :me & ene l DONOTKNOW l DONOTKNOW

DEPARTMENT OF HEAL TH & HUMAN SERVICES Public Health Service

Great Plains Area Indian Health Service Federal Building, Room 309 Aberdeen, SD 57401

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

STANDARDS OF CONDUCT

STANDARDS OF ETHICAL CONDUCT

SUPPLEMENTAL STANDARDS OF ETHICAL CONDUCT

EMPLOYEE CERTIFICATION

I have been provided a copy of the U.S. Department of Health and Human Services Standards of Conduct regulations which apply to all lndlan Health Service Officers and Employees (5 CFR Part 2635). I have been advised that the Aberdeen Area Deputy Ethics Counselor Is Acting HR Officer, Patricia Tomhave-Dodge who can be reached at 605-226-7553 if I have any questions.

I understand that it is my responsibility to read and familiarize myself with the regulatory contents. I understand that I may discuss questions or concerns related to my responslbi/lties, conduct and financial interests with this individual or his/her designated representative.

Employee Signature Date

PLEASE PRINT OR TYPE:

Employee Name: ------------

Title:

Location: