WOC Renewal Application Packet

DEPARTMENT OF VETERANS AFFAIRS VA San Diego Health Care System

3350 La Jolla Village Dr. San Diego, CA 92161

MemorandumFrom: Director, Research Staffing Section (151)

Subj: ACTION REQUESTED: VA Research WOC Renewal Packet

To: WOC Renewal Applicant

Hello,

It is time to renew your WOC appointment with Research Service. You are receiving this notice approximately 60 days in advance of your WOC appointment expiration date. Your action is requested to respond to this notice as quickly as possible to avoid delays in the renewal of your appointment

Research Staffing Section must have this packet at least 2 weeks prior to your VA Badge expiration date in order to allow sufficient time to process your renewal.

Your Research WOC appointment must remain current in order to continue working for the VA Research Department. You are NOT authorized to work in the Research Department should you allow your WOC appointment to expire.

Please fill this packet out on the computer to ensure it is legible.

ACTION ITEMS ASSOCIATED WITH THIS PACKET: Your Principal Investigators (PI/ Supervisor) signature or initials are required on a few of thesepages. Those fields are highlighted in blue. Your signature or initials are required on a few of these pages. Those fields are highlighted inyellow. Employee Health must sign off on the TB (Tuberculosis Surveillance) screening page BEFOREyou turn your renewal packet in. Please note: You may need to get a new PPD screening test if you have not had one in the last year. You must be fingerprinted PRIOR to submitting your packet in order to allow time for this to clearfor your badge to be issued. Although you may have been fingerprinted for your current appointment, VA now requires fingerprinting EACH time a badge is issued. If you are currently renewing a 6 month appointment, please contact Robert or Debbie toschedule an appointment to initiate a background investigation

If you are not planning to renew your WOC appointment, please ensure that your badge is returned to our office, either by mail or dropped off, on your last day of work.

Thank you,

Coral Ana, Research Staffing Section Supervisor

Research Staffing Section Points of Contact: • Robert Atienza, Staffing Intake Coordinator: 858-552-8585 x1159 / [email protected]• Debbie Lynn, Compliance Associate: 858-552-8585 x2505 / [email protected]• Coral Ana, Research Staffing Supervisor: 858-552-8585 x5980 / [email protected]

mailto:[email protected]



WOC Employee Contact and Work Information Please ask your Principal Investigator to assist you in completing this page

Date:

Research Staff Name:________________________ PI:______________________________________

Date of Birth: PIace of Birth:Position Title: Service:

Paid by: UCSD VMRF Other): Room #: Mail Code: SSN#:

Work Email (if none, please provide personal email address):

Office Phone: Lab Phone: Home Phone:

Home Address: Mailing Address

City State Zip

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Work Schedule: Full-time (40 hours) Part-time ( hours) Student: Y N

Work Days: S M T W Th F S Work Hours: AM to PM

Transportation Method: (i.e., car, carpool, coaster, bus, etc.) Please be advised that parking is limited at the VA and you may not qualify for parking privileges at the VA.

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Are you a licensed healthcare provider: Yes (please provide photocopy) No

License #: Expiration Date: ----------------------------------------------------------------------------------------------------------------------------------------------------------

How long do you plan to work in this position? 6 Months 1 Year 2 Years

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I understand that (1) this employee will not begin work until all paperwork has been approved; (2) that I am responsible for notifying Research Admin when this WOC employee terminates; and (3) that this WOC employee will complete all ofthe necessary training to complete his/her duties that he/she has been assigned and that documentation is submitted to Research Admin office and all training remains current.

P.I. Signature Date

PLEASE CHECK A JOB TITLE THAT BEST DESCRIBES YOUR WORK AT THE VA.

Date:

Research Staff Name: PI: Co-Investigator:

**NOTE: ALL CLERICAL POSITIONS ARE TITLED** “RESEARCH ASSISTANT”

List of Position Duties

Biological Science Aide Research Biologist/Biologist

Biological Science Lab Technician Research Biomedical Engineer

Biomedical Engineer Research Chemist

Biomedical Technician Research Health Science Specialist

Research Assistant** Research Health Scientist

Clinical Nurse Specialist Research Microbiologist

Clinical Research Psychologist Research Pharmacologist

Computer Programmer Research Physiologist

Computer Programmer Analyst Research Psychologist

Computer Scientist Research Speech Pathologist

Electronics Technician Statistician

Social Science Technician Research Pharmacist

Nurse Researcher Veterinarian

Physical Science Technician Psychologist

Psychology Aide Psychology Technician

Clinical Research Assistant Maintenance

VA San Diego Healthcare System (664) Scope of Practice for Research Service (Non-PI) Revision Date: 5/16/2013

Page 1 of 5

Scope of Practice for Research for NON-PI Renewal

Name: Research Job Title:

Email Address: Phone:

Principal Investigator (PI): ____________________________ Primary Supervisor (if not PI): ____________________________

Additional supervising PIs or alternate supervisors with same VA clinical privileges as PI: _______________________ / N/A EDUCATION

Education Degree Institution Degree Field Specialty Date Rcvd (Or Projected)Undergraduate Graduate Doctoral

Clinical License #: _________________ State: __________ Country: ___________________ Not Applicable Discipline of License : MD Nursing Psychology Resp. Therapy Social Work Other: _____________

*Psychology Only: APA-accredited PhD Program APA-accredited Internship – Institution:___________________ Training Program

Requests for Appointment in this category must be accompanied by TQCVL or RCVL list confirmation

Participating in a Formal Clinical Training Program through the VA (managed by Education Service)? No Yes

Start Date: _________ Planned Date of Completion: __________ Supervisor (if other than PI): _____________________ CLINICAL TRAINING PROGRAM (check one):

Medical Student Student Resident Clinical MS/PhD Student

Clinical MS/PhD Post-Doctoral Trainee Fellow Other (specify): ________________

The Scope of Practice is specific to the duties and responsibilities of research personnel as an agent of the listed Principal Investigator (PI) and/or alternate supervisor. As such he/she is specifically authorized to conduct research with the responsibilities outlined below. The supervisor must complete, sign and date this Scope of Practice. Research staff performing clinical care as part of research or performing research activities that may be considered clinical care must also be credentialed and privileged or have a scope of practice validated through a clinical service.

RESEARCH PROCEDURES: Research staff may be authorized to perform the following duties/procedures on a regular and ongoing basis. Research staff should initial boxes to identify and request specific job duties where appropriate. PI must initial where job duty is approved or denied. Research staff (employee) and PI initials indicate they are aware and agree to maintain current status of role-specific training as itemized below, and that Human, Animal, or Bench Research duties may ONLY be performed on active Human, Animal, or Bench Protocols with current approval by the VASDHS R&D Committee and applicable Subcommittee(s).

NATURE OF DUTY Staf

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Special Conditions

ACOS R&D Approval

YES NO

Research Preparatory Duties: Does Not Require Employee to Be on Active Protocol/Project Staff List Not Requested

Initiates submission of regulatory documents to IRB, IACUC, VA R&D committee and others (VMRF, FDA, IRC, etc).


Page 2 of 5

NATURE OF DUTY Staf

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Special Conditions

ACOS R&D Approval

YES NO

Human Subjects Research Duties: Performed ONLY on Active VASDHS Human Subjects Protocol on which Employee is Listed as Staff Not Requested

Accesses, records, or analyzes sensitive subject information while maintaining confidentiality. Maintains complete and accurate data collection for case report forms and source documents (Non-subject contact) – requires HRPP & GCP, Privacy & HIPAA Training

Provides education regarding study activities, or provides screening forms or documents to subjects and assists in completion without performing assessment activity. (Subject contact) – requires HRPP & GCP, Privacy & HIPAA, and Suicide Prevention Training

Obtains informed consent from research subject, documents consent in research subject’s medical record if applicable. (Subject contact) – requires HRPP & GCP, Privacy & HIPAA, and Suicide Prevention Training

Documents study activities in CPRS– requires HRPP & GCP, Privacy & HIPAA Training

Provides education and instruction of study medication use, administration, storage, and side effects, and notifies appropriate parties regarding adverse drug reactions– requires HRPP & GCP, Privacy/HIPAA, and Suicide Prevention Training

Schedules subjects using VistA or CPRS –requires VistA Scheduler training

Performs venipuncture to obtain specimens required by study protocol * Attach phlebotomy certificate* (VA privileged clinicians do NOTselect this duty, request Clinical Intervention Duty below). – requires HRPP & GCP, Privacy & HIPAA, & Suicide Prevention Training

Administers questionnaires, surveys, Mental Health instruments, or other assessment tools without clinical interpretation, diagnosis, intervention, or treatment. – requires HRPP & GCP, Privacy & HIPAA, and Suicide Prevention Training

Clinical Interventions Including Diagnosis, Interpretation, or Treatment: Performed ONLY on Active VASDHS Human Subjects Protocol on which Employee is Listed as Staff Not RequestedFull (not limited) clinical privileges or functional statement/clinical scope of practice required from appropriate clinical service. If clinical service has granted only limited privileges, then do not select Clinical Intervention Duty below, instead use “other duties” on next page to specify what limited clinical duties are being requested. Research Service does not approve clinical privileges but will confirm existing privileges prior to approving any duties in this category.

Physician-Specific

Nursing-Specific

Psychology-Specific

Other: Describe


Page 3 of 5

NATURE OF DUTY Staf

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Special Conditions

ACOS R&D Approval

YES NO

Animal Research Duties: Performed ONLY on Active VASDHS Animal Subjects Protocol on which Employee is Listed as Staff Not Requested

Animal Care, procedures, or surgery (as described on attached form) – requires Biosecurity, Biosafety, VMU Orientation, Working with the VA IACUC, and if applicable Waste Anesthetic Gases and species specific training designated by assigned protocol.

Laboratory Bench Research Duties: Performed ONLY on Active VASDHS R&D Project with Bench Research Component on which Employee is Listed as Staff

Not Requested Bench Research duties (specify on attached form)– requires Biosafety and Biosecurity Training

Works with de-identified human specimens (does NOT require HRPP & GCP training)

Works with identifiable human specimens – requires HRPP & GCP, Privacy & HIPAA Training

TO BE COMPLETED BY THE RESEARCH ADMIN OFFICE:

Required Role Specific Training for ANY Human Subject Duties or Human Specimens: VA Human Subjects Protection and Good Clinical Practices (HRPP & GCP)

Required Additional Training for Human Subjects Contact Duties: Suicide Prevention

Required Additional Training for Patient Scheduling Duties: VHA Scheduling, Electronic Wait List (EWL)

Required Training for Animal Research Duties: VMU Animal Orientation Working with the VA IACUC Waste Anesthetic Gases (WAG)

Required Training for Laboratory Bench Work: Biosecurity Biosafety

OTHER DUTIES (describe): ACOS R&D to Note Under Special Conditions If Duty Requires Employee to Be on Staff List of Active Protocol/Project

Not Requested

Mr./ Ms. is authorized to perform the following miscellaneous duties not otherwise specified in this Scope of Practice.

Staf

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Special Conditions ACOS R&D Approval

YES NO

Signature of Research Staff (employee) Date


Page 4 of 5

PRINCIPAL INVESTIGATOR STATEMENT:

This research Scope of Practice was reviewed and discussed with __________________________ on_____________. After reviewing education, competencies, qualifications, research practice involving human subjects, and individual skills as appropriate, I certify that he/she possesses the skills to safely perform the aforementioned duties/procedures. I am familiar with all duties/procedures granted to this employee in this Scope of Practice. The research staff (employee) and I agree to abide by the parameters of this Scope of Practice, all-applicable hospital policies and research related regulations.

I understand that (1) this employee will not begin work until all paperwork has been approved and the employee has been added to appropriate protocol/project staff lists as applicable to the category(s) of duties; (2) that I am responsible for notifying Research Admin Office when this employee terminates, (3) that this employee will receive all of the necessary training to complete his/her duties that he/she has been assigned and that documentation is on file in my office and copies submitted to Research Admin Office, and (4) I will ensure this employee completes all recurring training requirements prior to required renewal dates and will monitor their training status.

Principal Investigator/ Supervisor Date

CLINICAL SERVICE APPROVAL (applicable if clinical duties requested on Research Scope of Practice) Licensed Practitioners Operating under Approved Privileges (Medical Staff Office):

Full Clinical Privileges (check appropriate box ): Already Privileged In Process

Limited Clinical Privileges (check appropriate box & identify Responsible Clinician): Already Privileged In Process

Responsible Privileged Clinician who will review/monitor/co-sign all clinical activities:____________________________

Licensed Clinical Staff Operating under Clinical Scope of Practice/Functional Statement:

Full Authority to Act Under License/Scope Issued by Clinical Service (check appropriate ): Approved In Process

Limited Authority to Act Under License/Scope Issued by Clinical Service (check appropriate ): Approved In Process

Responsible Clinician who will review/monitor/sign all clinical activities: ______________________________

Unlicensed Staff/Trainees Permitted Limited Clinical Duties Under Supervision:

Unlicensed Professional working towards licensure (as permitted by specific VHA Policy and/or VASDHS Medical Center Policy)

Responsible Clinician who will review/monitor/sign all clinical activities: ____________________________

Trainee on RCVL or TQCVL List (processed as trainee through Education Service)

Responsible Clinician who will review/monitor/sign all clinical activities: ____________________________

Not authorized for clinical duties at VASDHS: Research Scope of Practice must not include duties requiring licensure or Clinical

Scope of Practice, and ID Badge / lab coat must not imply clinical credentials

Signature of Clinical Service / Section Chief Date Name of Service / Section

I have discussed my role with the Clinical Service Chief and agree to take responsibility for review and sign-off of all clinical interventions by this employee.

Responsible clinician concurrence signature: Not Applicable

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Page 5 of 5

Research Admin OFFICE USE ONLY:

Eligible for licensure by education and training Yes No

Education Verification Yes/Valid Thru: ________ No Not Applicable

Privileges or License Verification Yes/Valid Thru: ________ No Not Applicable

Clinical Training Program Confirmation (RCVL or TQCVL) Yes/Valid Thru: ________ No Not Applicable

Program: ___________________________

Research Admin Office Review Date ============================================================================================ Associate Chief of Staff R&D Review:

Approved (check as appropriate below for any conditions of approval) Current Clinical Privileges must be maintained at all times (attach copy of privileges to this scope) Current Credentialing as a Non-LIP must be maintained at all times (attach copy of current appointment) Current Clinical License must be maintained at all times (attach copy of clinical license to this scope) Current Certification of Competency must be on file and attached to this scope Verification of Education required (attach evidence of completion to this scope) Must maintain active trainee status with VASDHS Education Service to perform clinical duties permitted on this

Research Scope; termination of trainee status would require issuance of privileges in order to maintain clinical duties

Limited Privileges or Limited Clinical Scope of Practice requires review and co-signature of all clinical assessments, diagnosis, treatment, or intervention by Responsible Clinician identified by Clinical Service Chief on prior page

Limited authority to function as Unlicensed Professional working towards clinical licensure under Medical Center Policy; requires review and co-signature of all clinical assessments, diagnosis, treatment, or intervention by Responsible Clinician identified by Clinical Service Chief on prior page Licensed Professional hired to fulfill duties that do not require licensure/privileges; per communication from Office of Quality and Safety, Director of Credentialing and Privileging, dated April 22, 2012, VetPro Credentialing is NOT required. Employee MUST NOT present to subjects as a licensed, certified, or privileged clinician, and MUST NOT wear lab coat or ID badge indicating clinical training

Foreign Medical Graduate, does not require VetPro Credentialing but MUST NOT present to subjects as a clinician, and MUST NOT wear lab coat or ID badge indicating clinical training

Not authorized to perform ANY duties that require clinical licensure, privileges, or certification; Other (specify): ______________________________________________________________________________

Approved pending VetPro Credentialing: As Licensed Independent Practitioner (LIP) through Medical Staff Office

Full Clinical Privileges as indicated by Clinical Service/Section Chief Above Limited Clinical Privileges as indicated by Clinical Service/Section Chief; any clinical duties listed on this Research Scope require monitoring and sign-off by responsible clinician specified above.

As non-LIP through Human Resources Full Authority to work under Clinical Scope of Practice as non-LIP as indicated by Clinical Service Chief above.

Limited Authority to perform duties specified on this Research Scope of Practice as non-LIP as indicated by Clinical Service Chief above; any clinical duties listed on this Research Scope require monitoring and sign-off by responsible clinician specified above.

Disapproved (state reason) __________________________________________________________________________________

Identify frequency of Scope Review if required by ACOS R&D: Annual Scope Review--Scope Includes Clinical Duties

Review by ____________________ (projected change in clinical status requires review earlier than annual) Date

Subject to 10% Annual Quality Assurance Review of Scopes with non-clinical Human Subjects Research duties

Not Applicable: Scope does not include ANY Human Subjects Research duties

Gerhard Schulteis, PhD. Date ACOS R&D

IN CASE OF A MEDICAL EMERGENCY WHAT TO DO IF YOU ARE INJURED ON VA PROPERTY

1. In case of a medical emergency involving respiratory distress or unconsciousness here in the VA San DiegoHealthcare System (VASDHS), have someone call x3333 and report a Code Blue. For all other medicalemergencies requiring assistance call the Emergency Department at x3386.

2. Immediately report the injury to the principal investigator, office manager, or co-worker.

3. If you are able to walk, but need medical assistance, proceed to Employee Health on the 1st floor, room #1211 and be seen by the doctor. Follow all instructions given to you by Employee Health.

4. If you elect to see your own doctor, get the proper forms from nurse in employee health and follow theinstructions.

5. If you are a VA Paid Employee, as soon as you are able, see Yolanda Castro in Research Administration onthe 6th floor, Room# 6004 to complete the Occupational Workers Compensation Program (OWCP) forms.

6. If you are a UCSD Paid employee, you will need to notify your UCSD HR.

7. If you are a VMRF Paid employee, you will need to notify VMRF at x7606.

8. If your injury is to the extent where you are admitted to the Emergency Department (ED) here at theVASDHS, please remember that you may be liable for the expenses that are not covered by your respectivemedical insurance company. Many times the person may be admitted to the ED, but then will be transportedto the hospital of choice by your insurance company. It is up to your medical insurance provider to make thatdecision so you need to contact them as soon as possible. If you are not able to do so, then you need tohave a family member or friend contact your insurance company for you.

9. If you have any questions please call Yolanda at x7014 or come and see her in room 6004.

Check All Boxes that Apply: Veteran UCSD-Paid VA-Paid VMRF-Paid

Person to contact in case of an emergency:

Printed First & Last Name Street Address

Phone Number City State

I have read this statement.

Printed First & Last Name Employee Signature Date

VA San Diego Healthcare System Occupational Health - Without Compensation (WOC) Clearance

BY APPOINTMENT ONLY - CALL EXTENSION 3214 FOR APPOINTMENT

Section I: TYPE OR PRINT LEGIBLY 1. Name: ________________________________________________ Male Female (last, first, middle initial) 2. Full Social Security: _____-_____-_______ 3. Date of Birth (mm/dd/yy)__________ 4. Service/Section: ________________/_____________ 5. Contact phone: _________________ 6. Email Address: ________________@_________________ 7. Agency affiliation: VA UCSD VMRF Student/Trainee Section II: Must be completed and signed by the Principal Investigator (PI)/Service POC:

(Prior to Occupational Health Appointment)

1. Anticipated Date of appointment for this WOC: ___________________________________ 2. Anticipated Length of appointment: _____________________________________________ 3. WOC Position Title: ____________________________________ 4. Service/Section: ___________________/__________________________ 5. Work location (be specific): _____________________ 6. Name of Service administrator or designated contact:______________________________ 7. Phone # and Extension of Service contact: _____________________________________ 8. Will this individual be in contact with human or primate blood, tissue samples or have direct

patient contact other than verbal interaction? Yes No IF “yes” please describe below: ________________________________________________________________________________ ________________________________________________________________________________ 9. Name of PI/Service POC: _________________________________________________

10. Signature of PI/Service POC: _______________________________ Date: _________ Section III: Occupational Health Use Only 1. Quantiferon: Date blood drawn____________

2. Tuberculosis surveillance: Baseline Annual Renewal

3. Initial: History of +ppd: Yes No Date of CXR:____________

4. If ppd negative date of reading: __________

5. Date next TB test due: ________________ Final Clearance Date: ________________OH Signature: __________________________________

FINGERPRINT REQUEST FORM Research WOC

INSTRUCTIONS: Please fill out section I completely, then bring this form to Police Service: Room 1508, Monday –Friday, 7:00-3:15. Points of contact in the fingerprint office are Richard or Gina at 858-642-3531.

Section I to be completed by the Employee

Name: Date: Other Names Used: Position Title:

Social Security Number: Service/Mail Code: RESEARCH / MC (151)

Phone: Email: Date of Birth: City/State/Country of Birth:

Country of Citizenship: Male Female Anticipated Start Date (EOD): Length of Appointment: 6 months 1 yr 2 yrs

Applicant Category (check one): Paid Fee-Basis Work-Study IPA Extern Intern (non medical)

Resident Student Volunteer Research WOC: UCSD VMRF OTHER:

Contractor Contract #: Contract Company:

Section II to be completed by Research POC or COTR

Service POC / COTR Sponsor: Robert Atienza Phone: 858-552-8585 x1159

Send Fingerprint Results to: Robert Atienza Mail Code: 151

Section III to be completed by Police Service

Date Completed:

Police Service Name: Signature:

Section IIII to be completed by HUMAN RESOURCES

SAC Completed Date:

HR Name:

HR Signature:

**UPON COMPLETION OF THIS FORM POLICE SERVICE WILL ROUTE THIS FORM TO HUMAN RESOURCES**

FINGERPRINT VERIFICATION FORM Research WOC

INSTRUCTIONS: Please fill out section I completely, then bring this form to Police Service with your Fingerprint Request form: Room 1508, Monday –Friday, 7:00-3:15. Points of contact in the fingerprint office are Richard or Gina at 858-642-3531.

Section I to be completed by the Employee

Name: Date: Position Title: Length of Appointment: 6 months 1 yr 2 yrs

Social Security Number: Service/Mail Code: RESEARCH / MC (151)

Phone: Email: Date of Birth: City/State/Country of Birth:

Country of Citizenship: Male Female

Section II to be completed by Research POC or COTR

Service POC / COTR Sponsor: Robert Atienza Phone: 858-552-8585 x1159

Send Fingerprint Results to: Robert Atienza Mail Code: 151

Section III to be completed by Police Service

Date Fingerprints Completed:

Police Service Name:

Signature:

**UPON COMPLETION OF THIS FORM RETURN TO RESEARCH ADMINISTRATION WITH YOUR WOC PACKET**

PIV Badge Request Form

Name: ___________________________ Date of Birth: __________________

Social Security Number: _____________ VA Computer Account: Y / N (va.gov only)

Place of Birth (city & state):_________________________

Research Job Title: ________________________________

E-Mail: _______________________________ Work Phone: _______________

Sex: M F

Race: ________________

Height: _______________ (feet ‘inches)

Weight: _______________ (pounds)

Eyes: _________________

Hair: _________________

Research Admin Office Use Only

NACI Submitted: _____________

NACI Issues: ___________________________________________________

NACI Re-submitted: ___________

NACI Closed: ________________

PIV Badge Processed: __________

ANNUAL RECORD OF EMPLOYEE COMPETENCE ORGANIZATIONAL

NAME:_________________________________________________________ POSITION: ____________________________________________________

SERVICE: __________________________________________________ SUPERVISOR: ____________________________________________ Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”

COMPETENCY & OUTCOMES

BEHAVIORS *

VALID (Circle

validation code)

DATE INITIALS

COMMENTS Supervisor Employee

Demonstrates Teamwork Assists others to complete work. D O R S T

Protects Patient Rights Protects patient confidentiality and privacy, including verbal, written and computer-generated information.

D O R S T

Manages Resources Manages work time. D O R S T

Acts in a Responsible Manner Meets timelines and completes tasks. D O R S T

Promotes Customer Satisfaction

Greets customers with a smile and eye contact.

D O R S T

Responds to customer requests and follows up as soon as possible.

D O R S T

Demonstrates Ethical Behavior Does not falsify data or records. D O R S T

Environmental Management Maintains clean work area, promotes facility cleanliness by wiping up own spills and/or notifying Environmental Management Service as soon as possible for needed clean up.

D O R S T

Infection Control Protects self and others by practicing proper hand hygiene and cough etiquette. Practices standard contact precautions.

D O R S T

Information Management Demonstrates knowledge and accurate use of computer systems as applicable to job position.

D O R S T

Maintains computer security by logging off and protecting passwords.

D O R S T

Updated April 16, 2013

Participates in Performance Improvement

Supports and helps implement improvements.

D O R S T

Respects Diversity in Others Demonstrates respect of cultural, ethnic, religious, gender, sexual orientation and disability differences in others during interactions.

D O R S T

Problem Solving/Conflict Resolution

Offers solutions to problems and conflicts. D O R S T

Provides Specific Population Appropriate Care

Veteran Specific: World War II; Korea; Cold War; Vietnam War; Gulf War; OEF/OIF/OND; PTSD; TBI; MST; Women’s Health

D O R S T

Age Specific Care: Young Adult (18-40); Middle Adult (40-65); Later Adult (65+)

D O R S T

Cultural Diversity and Belief/Spiritual Considerations: American Indian; Asian/Pacific Islander; Hispanic; African American; Educationally Disadvantaged; Mentally &/or Physically Disabled; Beliefs; Spiritual Issues

D O R S T

Each item is to be dated and initialed individually. The use of ditto marks or continuation lines are not permitted.

* VALIDATION METHOD CODES: D Demonstration O Observation R Record Review S Simulation T Test (ONLY for safety competencies) Circle the applicable validation code.

Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.

All of the competencies have been validated.

The employee requires further education to obtain the skills and techniques necessary to competently complete his/her job

duties. Employee will be given further instruction on and re-evaluated in 90 days.

Supervisor/Designee Signature _________________________________________________________________ Date ______________________________

Employee Signature _____________________________________________________________________________ Date ______________________________


ANNUAL RECORD OF EMPLOYEE COMPETENCE SAFETY

NAME:_________________________________________________________ POSITION: ____________________________________________________

SERVICE: __________________________________________________ SUPERVISOR: _____________________________________________ Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”


BEHAVIORS *

VALID (Circle

validation code)

DATE INITIALS


Safety risk in hospital environment Notifies supervisor of hazardous area.

D O R S T

Reporting procedures for incidents involving property damage, occupational illness, and injury to patients, staff, or visitors

Uses proper forms for reporting incidents.

D O R S T

Activates use of hospital color code system based on type of emergency

Calls Hospital Operator (x-3333) to activate Code Blue/Red/Yellow/Green/Purple/White.

D O R S T

Activates emergency protocol for Community Based Outpatient Clinics and other off-site VA locations

Calls 9-1-1. D O R S T

Fall Prevention and Management Plan

Can describe the organization’s Fall Prevention and Management Plan and knows the color code used to identify High Fall Risk Patients (yellow).

D O R S T

Actions to eliminate, minimize, or report safety risks

Initiates work order to have problem resolved.

D O R S T

Hospital-specific fire evacuation routes

Can describe evacuation routes out of work area.

D O R S T

Specific roles and responsibilities when at fire’s point of origin

Can demonstrate the process described by acronyms R.A.C.E. and P.A.S.S.

D O R S T


Specific roles and responsibilities when away from a fire’s point of origin

Is familiar with the alarm code. D O R S T

Use and functioning of fire alarm systems when required

Knows when and how to activate fire alarm.

D O R S T

Use and functioning of fire alarm systems when required.

Knows when and how to activate fire alarm.

D O R S T

Specific roles and responsibilities in preparing for building evacuations

Can articulate roles and responsibilities during evacuation of staff and patients.

D O R S T


*VALIDATION METHOD CODES: D Demonstration O Observation R Record Review S Simulation T Test (ONLY for safety competencies) Circle the applicable validation code.

Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.

All of the competencies have been validated.



Supervisor/Designee Signature _________________________________________________________________ Date ______________________________ Employee Signature _____________________________________________________________________________ Date ______________________________


ANNUAL RECORD OF EMPLOYEE COMPETENCE Job Specific

NAME: _________________________________________________________ POSITION: ____________________________________________________ SERVICE: __________________________________________________ SUPERVISOR: ____________________________________________

Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”


BEHAVIORS

* VALID (Circle

validation code)

DATE

INITIALS COMMENTS Supervisor Employee

D O R S T

D O R S T

D O R S T

D O R S T

D O R S T


* VALIDATION METHOD CODES: D Demonstration O Observation R Record Review S Simulation T Test (ONLY for safety competencies)

Circle the applicable validation code. Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.

All of the competencies have been validated. Note: Job Competencies are specific to the job the employee is assigned to.



Supervisor/Designee Signature _________________________________________________________________ Date ______________________________ Employee Signature _____________________________________________________________________________ Date ______________________________


ANNUAL RECORD OF EMPLOYEE COMPETENCE SUPERVISOR/MANAGER

NAME:_________________________________________________________ POSITION: ____________________________________________________

SERVICE: __________________________________________________ SUPERVISOR: ____________________________________________ Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”


BEHAVIORS *

VALID (Circle

validation code)

DATE INITIALS


Plans/Organizes Prioritizes work activities. D O R S T

Leadership Empowers staff to make decisions. D O R S T

Manages Conflict Facilitates constructive conflict resolution.

D O R S T

Recognizes and rewards competence

Recognizes and rewards individuals and teams for exceptional performance and special contributions.

D O R S T

Manages Operations and Resources

Uses performance measures to monitor operations.

D O R S T


* VALIDATION METHOD CODES: D Demonstration O Observation R Record Review S Simulation T Test (ONLY for safety competencies) Circle the applicable validation code.

Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency. All of the competencies have been validated.



Supervisor/Designee Signature _________________________________________________________________ Date ______________________________

Employee Signature _____________________________________________________________________________ Date ______________________________


Instructions for Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 03/31/2016

Read all instructions carefully before completing this form.

Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc.

Form I-9 Instructions 03/08/13 N Page 1 of 9EMPLOYERS MUST RETAIN COMPLETED FORM I-9

DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

What Is the Purpose of This Form?

Form I-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE).

Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors.

General Instructions

Section 1. Employee Information and Attestation

Newly hired employees must complete and sign Section 1 of Form I-9 no later than the first day of employment. Section 1 should never be completed before the employee has accepted a job offer. Provide the following information to complete Section 1:

Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any. Other names used: Provide all other names used, if any (including maiden name). If you have had no other legal names, write "N/A." Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters from Canada or Mexico may use an international address in this field.

Date of Birth: Provide your date of birth in the mm/dd/yyyy format. For example, January 23, 1950, should be written as 01/23/1950.

Employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form I-9 CNMI between November 28, 2009 and November 27, 2011.

E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephone number. Department of Homeland Security (DHS) may contact you if DHS learns of a potential mismatch between the information provided and the information in DHS or Social Security Administration (SSA) records. You may write "N/A" if you choose not to provide this information.

U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number.

www.justice.gov/crt/about/osc

Form I-9 Instructions 03/08/13 N Page 2 of 9

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the "A" prefix.

4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident, but are authorized to work in the United States, check this box.

a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, may write "N/A" on this line.

b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record your Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or as directed by USCIS or U.S. Customs and Border Protection (CPB).

(1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance).

(2) If you obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance fields.

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement)Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-274) on www.uscis.gov/I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Preparer and/or Translator Certification

If you check this box:

1. A citizen of the United States

2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one of the following four boxes provided on the form:

www.uscis.gov/I-9Central



2. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number and expiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unused fields.

3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first day the employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment.

4. Provide the name and title of the person completing Section 2 in the Signature of Employer or Authorized Representative field.

5. Sign and date the attestation on the date Section 2 is completed.

6. Record the employer's business name and address.

7. Return the employee's documentation.

If the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employer should also enter in Section 2:a. The student's Form I-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number);

and the program end date from Form I-20 or DS-2019.

Employers or their authorized representative must:1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine

and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents.

Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page of Form I-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Form I-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. If an employee presents a List A document, he or she should not present a List B and List C document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph.

Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins employment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. An employer may complete Form I-9 before the first day of employment if the employer has offered the individual a job and the individual has accepted.

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the form should they get separated.

Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even if they photocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place of completing Form I-9. Employers are still responsible for completing and retaining Form I-9.

Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer.

Section 2. Employer or Authorized Representative Review and Verification


2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that the receipt is valid in the "Expiration Date" field.

1. Record the document title in Section 2 under the sections titled List A, List B, or List C, as applicable.

When the employee provides an acceptable receipt, the employer should:

2. Record the number and other required document information from the actual document presented.

3. Initial and date the change.

1. Cross out the word "receipt" and any accompanying document number and expiration date.

By the end of the receipt validity period, the employer should:

See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at www.uscis.gov/I-9Central for more information on receipts.

Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized to work. When rehiring an employee within 3 years of the date Form I-9 was originally completed, employers have the option to complete a new Form I-9 or complete Section 3. When completing Section 3 in either a reverification or rehire situation, if the employee's name has changed, record the name change in Block A.

3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an unexpired Employment Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social Security card within 90 days.

Section 3. Reverification and Rehires

1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The employee must present the actual document within 90 days from the date of hire.

There are three types of acceptable receipts:

2. The arrival portion of Form I-94/I-94A with a temporary I-551 stamp and a photograph of the individual. The employee must present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporary I-551 stamp, or, if there is no expiration date, within 1 year from the date of issue.

Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below.

If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form I-9 for a new hire or when reverification is required.

Receipts

Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274) or I-9 Central (www.uscis.gov/I-9Central) for examples.

Unexpired Documents

For employees who provide an employment authorization expiration date in Section 1, employers must reverify employment authorization on or before the date provided.


http://www.dhs.gov/I-9Central


b. Record the document title, document number, and expiration date (if any).

3. Complete Block C if:

a. The employment authorization or employment authorization document of a current employee is about to expire and requires reverification; or

b. You rehire an employee within 3 years of the date this form was originally completed and his or her employment authorization or employment authorization document has expired. (Complete Block B for this employee as well.)

To complete Block C: a. Examine either a List A or List C document the employee presents that shows that the employee is currently authorized to work in the United States; and

2. Complete Block B with the date of rehire if you rehire an employee within 3 years of the date this form was originally completed, and the employee is still authorized to be employed on the same basis as previously indicated on this form. Also complete the "Signature of Employer or Authorized Representative" block.

1. Complete Block A if an employee's name has changed at the time you complete Section 3.To complete Section 3, employers should follow these instructions:

For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present.

If both Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the earlier date.

Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noncitizen nationals; or2. Lawful permanent residents who presented a Permanent Resident Card (Form I-551) for Section 2.

Reverification does not apply to List B documents.

Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766, Employment Authorization Document.

There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Act Statement" below.

What Is the Filing Fee?

USCIS Forms and Information

For more detailed information about completing Form I-9, employers and employees should refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274).

4. After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block, including the date. For reverification purposes, employers may either complete Section 3 of a new Form I-9 or Section 3 of the previously completed Form I-9. Any new pages of Form I-9 completed during reverification must be attached to the employee's original Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containing Section 3, with the employee's name entered at the top of the page, to the employee's original Form I-9. If there is a more current version of Form I-9 at the time of reverification, you must complete Section 3 of that version of the form.


ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

USCIS Privacy Act Statement

AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324a).

PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

DISCLOSURE: Submission of the information required in this form is voluntary. However, failure of the employer to ensure proper completion of this form for each employee may result in the imposition of civil or criminal penalties. In addition, employing individuals knowing that they are unauthorized to work in the United States may subject the employer to civil and/or criminal penalties.

A blank Form I-9 may be reproduced, provided all sides are copied. The instructions and Lists of Acceptable Documents must be available to all employees completing this form. Employers must retain each employee's completed Form I-9 for as long as the individual works for the employer. Employers are required to retain the pages of the form on which the employee and employer enter data. If copies of documentation presented by the employee are made, those copies must also be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the date of hire or 1 year after the date employment ended, whichever is later.

Photocopying and Retaining Form I-9

Form I-9 may be signed and retained electronically, in compliance with Department of Homeland Security regulations at 8 CFR 274a.2.

Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781. For TDD (hearing impaired), call 1-877-875-6028.

Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from the USCIS Web site at www.dhs.gov/E-Verify, by e-mailing USCIS at [email protected] or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.

You can also obtain information about Form I-9 from the USCIS Web site at www.uscis.gov/I-9Central, by e-mailing USCIS at [email protected], or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.

To obtain USCIS forms or the Handbook for Employers, you can download them from the USCIS Web site at www.uscis.gov/forms. You may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired), call 1-800-767-1833.

www.uscis.gov/e-verify

www.uscis.gov/e-verify

www.uscis.gov/I-9Central.

[email protected]

www.uscis.gov/forms

www.uscis.gov/forms

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 03/31/2016

START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Address (Street Number and Name)

E-mail Address Telephone NumberDate of Birth (mm/dd/yyyy)

Other Names Used (if any)

U.S. Social Security Number

►

Middle Initial

Apt. Number City or Town State Zip Code

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following):

An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy)

Signature of Employee: Date (mm/dd/yyyy):

Date (mm/dd/yyyy):Signature of Preparer or Translator:

Address (Street Number and Name) City or Town Zip CodeState

A lawful permanent resident (Alien Registration Number/USCIS Number):

A citizen of the United States

A noncitizen national of the United States (See instructions)

1. Alien Registration Number/USCIS Number:

For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:

If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:

2. Form I-94 Admission Number:

Country of Issuance:

Foreign Passport Number:

(See instructions)

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

First Name (Given Name)Last Name (Family Name)

- -

. Some aliens may write "N/A" in this field.

Page 7 of 9Form I-9 03/08/13 N

Employer Completes Next Page

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.)

OR

First Name (Given Name)Last Name (Family Name)

3-D Barcode Do Not Write in This Space

of 9Form I-9 03/08/13 N

Employee Last Name, First Name and Middle Initial from Section 1:

Section 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.)

CertificationI attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions.)

Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Employer's Business or Organization Address (Street Number and Name)

Last Name (Family Name) Employer's Business or Organization NameFirst Name (Given Name)

City or Town Zip CodeState

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below.

B. Date of Rehire (if applicable) (mm/dd/yyyy):

Document Title: Document Number: Expiration Date (if any)(mm/dd/yyyy):

Signature of Employer or Authorized Representative: Date (mm/dd/yyyy):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Middle InitialFirst Name (Given Name)Last Name (Family Name)

Issuing Authority: Issuing Authority:

Document Number:

Document Title:Document Title:

Document Number:

Issuing Authority:

List A OR ANDList B List C

Document Number:

Document Title:

Expiration Date (if any)(mm/dd/yyyy):

Document Title:

Issuing Authority:


Document Title:

Issuing Authority:


Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy):

Identity and Employment Authorization Identity Employment Authorization

Document Number:

Document Number:

Print Name of Employer or Authorized Representative:

3-D Barcode Do Not Write in This Space

of 9Form I-9 03/08/13 N

LISTS OF ACCEPTABLE DOCUMENTS

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

For persons under age 18 who are unable to present a document

listed above:

LIST A LIST B LIST C

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

8. Employment authorization document issued by the Department of Homeland Security

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

9. Driver's license issued by a Canadian government authority

1. U.S. Passport or U.S. Passport Card

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

3. School ID card with a photograph5. For a nonimmigrant alien authorized

to work for a specific employer because of his or her status:

6. Military dependent's ID card4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

7. U.S. Coast Guard Merchant Mariner Card

5. Native American tribal document8. Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Both Identity and

Employment Authorization

Documents that Establish Identity

Documents that Establish Employment Authorization

OR AND

All documents must be UNEXPIRED

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

6. U.S. Citizen ID Card (Form I-197)

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

APPOINTMENT AFFIDAVITS

(Position to which Appointed) (Date Appointed)

(Department or Agency) (Bureau or Division) (Place of Employment)

I, , do solemnly swear (or affirm) that-

A. OATH OF OFFICE I will support and defend the Constitution of the United States against all enemies, foreign and domestic;

that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties of the office on which I am about to enter. So help me God.

B. AFFIDAVIT AS TO STRIKING AGAINST THE FEDERAL GOVERNMENT I am not participating in any strike against the Government of the United States or any agency thereof,

and I will not so participate while an employee of the Government of the United States or any agency thereof.

C. AFFIDAVIT AS TO THE PURCHASE AND SALE OF OFFICE I have not, nor has anyone acting in my behalf, given, transferred, promised or paid any consideration

for or in expectation or hope of receiving assistance in securing this appointment.

(Signature of Appointee)

Subscribed and sworn (or affirmed) before me this day of , 2

at (City) (State)

(SEAL) (Signature of Officer)

Commission expires (If by a Notary Public, the date of his/her Commission should be shown) (Title)

Note - If the appointee objects to the form of the oath on religious grounds, certain modifications may be permitted pursuant to the Religious Freedom Restoration Act. Please contact your agency's legal counsel for advice.

Standard Form 61Revised August 2002Previous editions not usable

U.S. Office of Personnel Management The Guide to Processing Personnel Actions NSN 7540-00-634-4015

Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment)

Form Approved:OMB No. 3206-0182

U.S. Office of Personnel Management5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2011

Previous editions obsolete and unusable

Instructions

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions 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 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 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 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 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 information 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.






GENERAL INFORMATION1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not 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?

YES NO (If "NO", provide country of citizenship) ♦4. DATE OF BIRTH (MM / DD / YYYY)

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

♦ ♦

6. PHONE NUMBERS (Include area codes)

Day ♦Night ♦

Selective Service RegistrationIf 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, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

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

Military Service8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If you answered "YES," list the branch, dates, and type of discharge for all active duty. If your only active duty was training in the Reserves or National Guard, answer "NO."

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background InformationFor 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 resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 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 Corrections 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? (Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

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

YES NO

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

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 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

YES NO

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, 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 of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO






Additional Questions14. Do any of your relatives work 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, father-in-law,mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES," use item 16 to provide the relative's name,relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

YES NO

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

YES NO

Continuation Space / Agency Optional Questions16. Provide details 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 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 specific to your position and your agency is authorized to ask them).

Certifications / Additional QuestionsAPPLICANT: 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 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 application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions. When 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 information on and attached to this Declaration for Federal Employment, including any attached application 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, or for firing 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 eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health 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. Applicant's Signature: Date(Sign in ink)

17b. Appointee's Signature: Date(Sign in ink)

Appointing Officer: Enter Date of Appointment or Conversion

MM / DD / YYYY

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 eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? DATE:MM / DD / YYYY

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

YES NO DO NOT KNOW

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

WOC Renewal Application Packet

Documents

Transcript of WOC Renewal Application Packet