Addendum to Declaration for Federal Employment

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 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 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 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.

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.

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 of 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 are voluntary, required to obtain a benefit, or mandatory; and the nature and extent of confidentiality to be provided, if any. Public reporting burden for this collection of information is estimated to average 15 minutes per response.

FORM APPROVED: O.M.B. NO. 0917-0028    Expires 02/28/2009

Vacancy Announcement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
INDIAN HEALTH SERVICE
NAVAJO REGION

THIS POSITION IS LOCATED IN A TOBACCO-FREE ENVIRONMENT.

POSITION TITLE

GRADE/SALARY

LOCATION AND DUTY STATION:

NUMBER OF VACANCIES:

PROMOTION POTENTIAL:

WHO MAY APPLY:

TRAVEL/MOVING EXPENSES:

GOVERNMENT HOUSING:

DUTIES:

YOUR DESCRIPTION OF WORK EXPERIENCE, LEVEL OF RESPONSIBILITY, AND ACCOMPLISHMENTS WILL BE USED TO DETERMINE THAT YOU MEET THE FOLLOWING REQUIREMENTS.

BASIC REQUIREMENTS:

ADDITIONAL SELECTIONS:

INDIAN PREFERENCE:

SELECTIVE SERVICE CERTIFICATION:

EQUAL EMPLOYMENT OPPORTUNITY:

EACH APPLICATION FORM AND DOCUMENT FORM MUST BE INDIVIDUALLY IDENTIFIED BY THIS ANNOUNCEMENT NUMBER.

Supplemental Questionnaire

DENTAL OFFICER, GS-680-11/12

1. ABILITY TO WORK INDEPENDENTLY.

What was the duration of these activities?

Who can verify this information? (Please provide telephone number.)

2. ABILITY TO MEET AND DEAL WITH A VARIETY OF INDIVIDUALS.

What was the duration of these activities?

Who can verify this information? (Please provide telephone number.)

3. ABILITY TO COMMUNICATE IN WRITING.

What was the duration of these activities?

Who can verify this information? (Please provide telephone number.)

4. ABILITY TO COMMUNICATE ORALLY.

What was the duration of these activities?

Who can verify this information? (Please provide telephone number.)

5. ABILITY TO MAKE SOUND CONCLUSIONS.

What was the duration of these activities?

Who can verify this information? (Please provide telephone number.)

CERTIFICATION

I certify that all of the statements made in the above questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

Geographic Availability

NAME:   SOCIAL SECURITY:

Place an "X" next to the location(s) for which you wish to be considered.

HOSPITALS

CLINICS