Section J - Contractor Forms.pdf

(PLEASE COMPLETE AND RETURN)

LICENSURE REOUIREMENT

PERSONAL AND NONPERSONAL SERVICES CONTRACTORS SHALL BE SUBJECT TO THE SAME

QUALITY ASSURANCE, CREDENTIALS, LICENSURE, AND OTHER QUALIFICATION STANDARDS

AS THOSE REQUIRED OF IHS 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 IHS FACILITIES. THE CONTRACTING OFFICER WILL INSERT THE FOLLOWING

CERTIFICATION STATEMENT JN ALL PURCHASE ORDERS AND CONTRACTS FOR

PROFESSIONAL MEDICAL SERVICES:

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

REVOKED IN 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 ATE(S):

STATE LICENSURE NO. ISSUE DATE

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

STATE LICENSURE NO. ISSUE DATE

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

PROVISIONS OF THE PROGRAM FRAUD CIVIL REMEDIES ACT OF 1986 (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 THE OMISSION.

SIONA TURE OF PRACTITIONER DATE

AGREEMENT TO A TEMPORARY WAIVER OF CHARACTER

INVESTIGATION (FOR GOVERNMENT EMPLOYEES, CONTRACTORS,

STUDENTS AND VOLUNTEERS)

Per your request, the Aberdeen Area Indian Health Service 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.

Employee, Student, Volunteer, Contractor DATE

Your signature indicates you are taking the responsibility to assure Human Resources and/or the Senior Contracting Officer, 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 NACI. 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)

SIONA TURE OF INDIVIDUAL RESPONSIBLE

FOR DIRECT SIGHT MONITORING

CHIEF EXCUTIVE OFFICER

DATE

DATE

Declaration for Federal Employment* c•Thfs form may also be used lo assess fitness for federal contract employment)

Fann~ OMS No. 3206-0182

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

The information collected on this form is used to determine your acceptability for Federal and Federal contract emplo ment and our enrollment status. in the ~ovemment's Life Insurance program. You may be asked to complete this form at any time ~uring the ~ring process. Follow instructions that the agency pr~vides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other matenals 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 respon~es 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 title 5, U.S. Code. Section 1104 of title 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 lnvestlgalfon 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. Publlc 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 suitability 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; prospective non-Federal employers concerning tenure or employment, civil service status, length of service, and the dale and nature of action for separation as shown on the SF 50 (or authorized exception) or 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 or 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 Information Is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including lime 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. 1302. 3301, 3304. 3328 & 8710

Optional Form 3Cll Ro-OCIDbet2011

PtvvfOUS acli1iCOll-Oand-

Form App<ovc<l.

OMS No. ~206-0182

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

GENERAL INFORMATION

1. FULL NAME (Provide your full name. If you have only Initials in your name, provide them and indicate "Initial only". If you do no\ have a middle name, indicate "No Middle Name". If you are a •Jr.,'' "Sr.," etc. enter this under Suffix. First. Middle, Last, Suffix)

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

3b. ARE YOU A U.S. CITIZEN? 4. DATE OF BIRTH (MM I DD I YYYY)

I YES 0 NO (II "NO", provide country ol citizenship) + •

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc) 6. PHONE NUMBERS (Include area codes)

+ Day +

• Night •

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

7a. Are you a male born after December 31, 1959? G YES [", NO (lf"NO", proceed lo 8.)

7b. Have you registered with the Selective Se Nice System? l l YES (If "YES", proceed lo 8.) [ « NO {II "NO", proceed to 7c.)

7c. lf"NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military? rJ YES (lf ''YES", provide information below) I NO

If you answered "YES,• list the branch, dales, and type of discl1arge for all acUve duty.

If your only active duly was training in l/ie Reserves or National Guard, answer "NO.•

- - J

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 g, 10, and 11, your answers should include convictions resulting from a plea of nolo conlendere (no contest), but omit (1) traffic fines of S300 or less, (2) any violation 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 conviction set aside under the Federal Youth Correct.ions Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole? L I YES l.J NO (Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES,• use item 16 to provide the dale, explanation of the violation, place of occurrence, and the name and address or the 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.") ff "YES,• use item 16 lo provide the date, explanation of l/1e violation, place of occurrence, and Ille 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 lo provide the date, explanation of tfle violation, place 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 dale, 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, loans, overpayment of benefi\s, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES,• use item 16 to provide the type, length, and amount ofl/1e delinquency or default. and steps that you are toking to correct Ille error or repay t11e debt.

[1 YES

I YES

1 1 YES

C: YES

[l NO r NO n NO

C NO

U.S. Office of Personnel Management 5 u.s.c. 1302, 3301, 3304, 3328 & 8716

Oplionol f'orm 300 Revised October 2011

Previous oditions obsolclc and unuS<>blo rT111s form may also be used lo asaess fitness for federal contract employment)

Form AppOWld:

OM8No. 32DIMl182

AddHlonal Questions

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

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, r : YES r NO father..fn-law,mother.fn-law, son-In-law, daughter-In-law, brother-In-law, alster..fn-law, stepfather, stepmother, stepao~, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES,• use item 16 to provldll the relatives name,relationshlp, and the dllpartment agency, or branch of the Armed Forr:es for which your relative works.

15. Do you receive, or have you ever appHed for, retirement pay, panslon, or other retired pay based on military, r YES r-__ .. · NO Federal clvlllan, or District of Columbia Government service? 1 -~

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

16. Provide delalla requested In Items 7 through 15 and 18c In the space below or on attached sheets. Be swa to Identify attached sheets with your name, Social Security 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 specJric to your position end 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 thJs form and all 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 appllcatlon materials that your agency has attached to this fonn. If any information requires correction to be accurate as of the date you are signing, make changes on this fonn or the attachments and/or provide updated lnrormatlon on additional sheets, lnitla6ng and dating all changes and additions.

'Mien this form 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 appllcatlon materials, is true, correct, complete, and made In good faith • I understand that a false or fraudufent answer to any question or Item on any part of this declaration or Its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punlshabfe by fine or Imprisonment. I understand that any Information I give may be Investigated for purposes of detennlnlng eUglblrrty for Federal employment as allowed by law or Presldentlal order. I consent to the release of Information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other lncflVfduals and organizations to Investigators, personnel speclafists, and other authorized employees or representatives of the Federal Government I understand that for financial or lending Institutions, medlcal Institutions, hospitals, health eare professionals, and some other sources of -lnfonnatlon, a separate specific release may be needed, and I may be contacted for such a release at a later date. ,-------...... --....., Appointing Officer:

17a. Applicanfs Signature: Date EtllsOl!llaf~wc-.ian

(Sign In Ink) MM I DD/ YVV'f

17b. Appointee's Signature: ...,_ ________________ Date ------ (Sign In Ink)

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

188. When did you leave your last Federal job?

18b. 'Mien you worked for the Federal Government the last time, did you waive Basic Ufe Insurance or any type of optional life Insurance?

MMIOD/YYYY

DATE:

rves r NO

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

U.S. Office of Personnel Management 6 u.s.c. ,.. 3301, 3304, :me & 87t8 r DONOTKNOW r DONOTKNOW

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

Child Care & Indian Child Care Worker Positions

Item 16. Agency Specific Questions

OMB Approved Fonn No. 0917-0028

Esplratlon Date: 11/3012015

Social Security Number:-------------- (Please print)

Job Title in Announcement: Announcement Number:

Section 231 of the Crime Control Act of 1990, Public Law 101-64 7, 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 lOI-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 no lo 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 ofa 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:

I. 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 ofnolo 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 (I) my response to these questions is made under penalty of perjury, which is punishable by fine under title I8 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 StatemenJ: In accordance with Paperwork Reduction Act {S CFR I 320.8 (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 cal/ected; 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 ore voluntary, required to obtain a benefit (citing authority) , or mandatory (citing authority);

and the nature and utent of confidentiality to be provided, if any (citing authority). Public reporting burden for this collection of information Is estimated to overage 12 minutes per response, Including lime for reviewing lmtructions, searching uistlng data sources, gathering and maintaining the necessary data, and completing and rnlewlng the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information to the /HS PRA Information Collection Clearance Staff. I 2300 Twlnbrook Parkway, Suite 4SO, Rockville, MD 20852. Please do not send completed data collect/on Instruments to this address.