S02 Atch N Fingerprint Request Form I9 - 2 pages.pdf
PDF 124 KB Posted
- Solicitation number
- 36C26326R0046
About this file
This document is Appendix B to a federal contract solicitation, containing two components: the NWIHCS VA Police Service Fingerprint Request Form and PIV Identity Documentation Criteria.
The Fingerprint Request Form is used by the Nebraska-Western Iowa Healthcare System (NWIHCS) VA Police Service to collect personal identification information from individuals requiring fingerprinting, including name, Social Security number, date of birth, physical descriptors, citizenship status, and employment affiliation. The form designates sections for Human Resources or sponsoring services to indicate VA employment status (full-time, part-time, with or without compensation, trainee, faculty, or contract employee), assignment duration over 120 days, direct patient care provision, and computer access requirements. VA Police complete identity verification using driver's license or passport information and record fingerprinting completion details. Fingerprinting services are conducted in Omaha (walk-in basis, Mondays-Fridays, 8:00-11:30 a.m. and noon-4:00 p.m. at Main Hospital Room B804) and Lincoln, with contractor personnel required to submit completed forms to Contracting at Building C, Room 101 for Omaha and Lincoln facilities, or to HR for Grand Island facility. The PIV Identity Documentation Criteria establishes that two forms of identification are required, either two from Federal or State Government-issued picture IDs or one government-issued picture ID combined with one non-government acceptable form. Documentation cannot be expired (except U.S. Passport), handwritten, or photocopied, and names must match VA PIV Registration Portal records.
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Text version
01 00 00 – Appendix B
01 00 00 - Appendix B - 1 of 2
NWIHCS VA POLICE SERVICE
FINGERPRINT REQUEST FORM
NAME (Last, First, Middle):
SOCIAL SECURITY NUMBER:
DATE OF BIRTH (YEAR/MONTH/DAY):
ALIAS (MAIDEN NAME):
GENDER: RACE/ETHNIC BACKGROUND:
EYE COLOR: HAIR COLOR:
HEIGHT: Feet: Inch: WEIGHT: Lbs:
PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
CURRENT STREET ADDRESS:
CITY, STATE, POSTAL CODE:
CITIZENSHIP:
OCCUPATION:
EMPLOYER / SCHOOL AFFILIATION
AGENCY USE ONLY BELOW THIS LINE
TO BE COMPLETED BY HUMAN RESOURCES OR SPONSORING SERVICE
INDIVIDUAL’S VA STATUS:
FULL TIME VA EMPLOYEE PART TIME VA EMPLOYEE WITH OUT COMPENSATION (WOC)
AFFILIATING TRAINEE (STUDENT) AFFILIATING FACULTY CONTRACT EMPLOYEE
ASSIGNMENT OVER 120 DAYS YES NO
PROVIDES DIRECT PATIENT CARE YES NO
COMPUTER ACCESS REQUIRED YES NO
VA POLICE USE ONLY
IDENTITY VERIFICATION
DRIVERS LICENSE NUMBER: STATE OF ISSUE:
OR
PASSPORT NUMBER: COUNTRY OF ORIGIN:
FINGERPRINTS CONDUCTED BY: DATE COMPLETED:
The VA Police conducts fingerprinting in Omaha and Lincoln. Fingerprinting in Omaha is on a walk in basis Mondays-Fridays from 8:00 – 11:30 a.m. and Noon – 4:00 p.m. in the Main Hospital Room B804. For assistance or questions please call 995-5818.
CONTRACTOR PERSONNEL: FOR THE OMAHA AND LINCOLN FACILITIES SEND THE COMPLETED FORM TO CONTRACTING AT Building C, Room 101. FOR THE GRAND ISLAND FACILITY SEND THE COMPLETED FORM TO HR.
NOTICE: Access to this information is limited to AUTHORIZED PERSONS ONLY. Information may not be disclosed from this document unless permitted pursuant to 38 CFR 1.500 – 1.599. These records may not be altered or destroyed except as authorized by 38 CFR 1.579. This transmission is intended only for the use of the person or office to whom it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that receipt of this message does not waive any applicable privilege or exemption from disclosure and that any dissemination, distribution, or copying of this communication is prohibited. VA follows the requirements of the Privacy Act, which protects your personal information that VA maintains in “systems of records”. If you have received this communication in error, please notify us immediately at the telephone number shown above. Thank you.
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01 00 00 – Appendix B
01 00 00 - Appendix B - 2 of 2
- - - END OF SECTION 01 00 00 - - -
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