Self Certification of Continuous Service.pdf

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Replace Linear Accelerator at Greater Los Angeles VAHCS
Solicitation number
36C25821B0004
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This document contains a federal contract opportunity solicitation for replacing a linear accelerator at the Greater Los Angeles Veterans Health Administration Healthcare System. The solicitation seeks a contractor to completely prepare the site for building operations including demolition, coordinate with the government's equipment provider, and furnish labor and materials to perform work including renovating rooms for the linear accelerator, control room, mechanical room, and data server room. Additional requirements include replacing ceiling and flooring, rewiring, providing new lead shielding as required, installing a new air compressor and dryer system along with piping, two 2-ton HVAC units and a dedicated fan coil unit for gantry cooling with new ductwork. The contractor must also install new drywall, finishes, casework and paint, revise the fire protection system as required, and furnish and install a ceiling-mounted patient lift with a minimum 770-pound carrying capacity. The expected construction period duration includes all pre-construction activity and post-construction testing, third-party inspections and commissioning.

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DEPARTMENT OF VETERANS AFFAIRS

PERSONNEL SECURITY ADJUDICATION CENTER

Self Certification of Continuous Service

I hereby certify my break in service from my last federal employment is indicated by the block checked below.

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:

VA 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 working for the federal government.

Self Certification of Continuous Service Form Revised February 28, 2020

Previous Versions are Obsolete

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 .