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Revised: 24‐September‐2013
of the Health Sciences, Civilian Human ResourcesUNIFORMED SERVICES UNIVERSITY
Manager’s Guide for Staffing & Classification Actions
1. FACT SHEETS
Fact Sheet ‐ Request for Personnel Action (RPA) for GS & FWS Recruitment Action. Fact Sheet ‐ RPA for GS & FWS Reassignment Action. Fact Sheet ‐ RPA for GS & FWS Career Ladder Promotion Action. Fact Sheet ‐ RPA for AD Recruitment Action. Fact Sheet ‐ RPA for Hiring Volunteers. Fact Sheet ‐ Instructions for Administratively Determined Search Committees. Fact Sheet – Establish an AD Position Description.
2. SAMPLE – RPAs
Sample RPA for GS & FWS Recruitment Action. Sample RPA for GS & FWS Reassignment Action. Sample RPA for GS & FWS Career‐Ladder Promotion. Sample RPA for AD Recruitment Action. Sample RPA for Hiring Volunteers. Sample RPA for Establishing AD Position Description.
3. FORMS & GUIDANCE
Request for Personnel Action (RPA)‐Fillable Form. Instructions for Completing an RPA. Position Description Cover Sheet (Optional Form 8‐OF 8) with instructions – Fillable Form. Sample OF 8. Certification of Medical Examination (Optional Form 178 ‐ OF 178). CHR Recruitment Checklist. Template for Justification Memorandum. Administratively Determined (AD) Salary/Compensation Request Form. Parental Permission Form. Work Permit Application. Volunteer Agreement Form (DD Form 2793). Work Assignment for a Minor (USUHS Form 6050). USUHS Instructions 6004 Minors Employed at the University. Sample Position Descriptions (Chairperson, Full Professor, Associate Professor, Assistant
Professor, Research Associate and Post‐Doctoral Fellow) USUHS 1100, SOM Procedures, Enclosure 3 (January 2003) GSN Procedures, Enclosure 4 (August 2004) SOM DPM‐001‐06 (9‐March‐2006) GSN Policies and Procedures 2009‐01 (30‐September‐2009)
13 April 2012 Page 1
Fact Sheet Staffing and Classification
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Request for Personnel Action (RPA) for GS/FWS Recruitment Actions
The following provides guidance and information on the appropriate documentation needed to initiate a GS/FWS recruitment action.
• Departments should consult with their designated CHR Staffing & Classification Specialist to discuss the position and available hiring options before submitting a recruitment action to the CHR.
• Supervisors should review the subject position description (PD) to ensure that it is accurate before submitting a recruitment action.
• The department will prepare a RPA for the recruitment action and will include the following information. See sample RPA for GS/FWS recruitment action and the instructions for completing an RPA - Sections 2 and 3.
Indicate on the RPA if the position is new or vice an employee that separated. The RPA must be signed and dated by the immediate supervisor and authorized by
the appropriate Chair, Department/Activity Head, or higher level official in the chain of command.
Completed Recruitment Checklist (See CHR Recruitment Checklist - Section 3)
• When the position is a vice recruitment action, the following documents will also be required and must accompany the RPA:
A copy of the position description (PD) including the completed PD cover sheet
(Optional Form - OF 8). If the position is a career ladder position, include appropriate grade level PDs (with
OF 8) and statement(s) of difference. See sample OF 8 with instructions - Section 3.
If the position is a WS, WL, or WG position or a position that requires a medical exam include the Certification of Medical Examination Form (OF178), if applicable. See copy of OF 178 - Section 3.
• When the position is new, re-described, or a restructure of the grade level of a vice
position, the following documents will be required and must accompany the RPA:
A copy of the new and old PDs including completed PD cover sheets (OF 8). See sample OF 8 - Section 3.
A written justification for initiating the new position, redescription, or restructure of the vice position to include how the department expects to fund the position if additional funds are required. See justification memorandum template - Section 3.
13 April 2012 Page 2
RPA for GS/FWS Recruitment Actions Fact Sheet
A current and proposed organizational chart of the subject department or division showing the location of the new or restructured position.
If the position is a career ladder position include appropriate grade level PDs (with OF 8) and statement(s) of difference.
If the position is a WS, WL, or WG position or a position that requires a medical exam include an OF178, if applicable.
• The department will submit the recruitment action to the CHR-Staffing & Classification
Division for review and processing. Note: All RPAs must be signed and dated. RPAs received with incomplete or inaccurate information will be returned to the originator.
13 April 2012 Page 1
Fact Sheet Staffing and Classification
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Request for Personnel Action (RPA) for GS/FWS Reassignment Actions
The following information provides guidance on the appropriate documentation needed to initiate a GS/FWS reassignment action:
• Departments should consult with their designated CHR Staffing & Classification Specialist to discuss the process of reassigning an employee before submitting the reassignment action.
• The department will prepare an RPA for the reassignment action (an assignment to a
position at the same grade level). See Sample RPA for GS/FWS reassignment action and the instructions for completing an RPA - Sections 2 and 3. The RPA must be signed and dated by the immediate supervisor of the employee’s
current position and signed by the appropriate Chair, Department/Activity Head or higher level official in the chain of command.
• The following documents will be required and must accompany the RPA.
A copy of the position description (PD) including the PD cover sheet (OF 8) to
which the employee will be reassigned. See sample OF 8 - Section 3. Annotate any special requirements in Part D of the RPA (e.g. security clearance,
drug test, physical, DAWIA, etc).
• The department will submit the RPA for the reassignment action to CHR, Staffing & Classification Division, for review and processing.
Note: All RPAs must be signed and dated. RPAs received with incomplete or inaccurate information will be returned to the originator.
13 April 2012 Page 1
Fact Sheet Staffing and Classification
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Request for Personnel Action (RPA) for GS/FWS Career Ladder Promotion Actions
The following information provides guidance on the appropriate documentation needed to initiate a GS/FWS Career Ladder Promotion action.
• Departments should consult with their designated CHR Staffing & Classification Specialist to discuss the requested career ladder promotion before submitting an RPA.
• The department will prepare an RPA for the promotion action. See sample RPA for career ladder promotion action and the instructions for completing an RPA - Sections 2 and 3. The RPA must be signed and dated by the immediate supervisor of the employee and
signed by the appropriate Chair, Department/Activity Head or higher level official in the chain of command.
• The following documents are required and must accompany the RPA.
A copy of the higher graded position description (PD) to which the employee is being
promoted including the Optional Form (OF8). An email or brief memorandum to CHR from the immediate supervisor stating that the
employee meets the proficiency level required for advancement to the next higher grade level of his/her position.
• The department will submit the RPA for the promotion action to the CHR, Staffing &
Classification Division, for review regulatory sufficiency and processing.
Note: The RPA must be signed and dated. RPAs received with incomplete or inaccurate information will be returned to originator.
13 April 2012 Page 1
Fact Sheet Staffing and Classification
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Request for Personnel Action (RPA) for AD Recruitment Actions
The following provides guidance and information on the appropriate documentation needed to initiate an AD recruitment action.
• Departments should consult with their designated CHR Staffing & Classification Specialist to discuss the position and available hiring options before submitting a recruitment action to the CHR.
• Supervisors should review the subject position description (PD) to ensure that it is
accurate before submitting a recruitment action.
• Department will prepare a RPA for the recruitment action and include the following information. See sample RPA for AD recruitment action and the instructions for completing an RPA - Sections 2 and 3. The RPA will specify if the position is new or vice an employee that separated. The RPA will specify if the position is in the tenure track or the non-tenured track. The RPA must be signed by the department Chair or head and authorized/signed
by the appropriate Dean, Vice President, Director of AFRRI, or the President. • If the position is a vice recruitment action, the following will be required and must
accompany the RPA:
A copy of the position description (PD) including the completed PD cover sheet (Optional Form - OF 8).
A draft of the proposed advertisement. • If the position is new or a restructure in the academic rank (e.g., Assistant Professor to
Associate Professor, etc.) of a vice position, the following will be required and must accompany the RPA:
A copy of the new and old PDs including completed PD cover sheets (OF 8). See
sample OF 8 - Section 3. A justification memorandum for initiating the new position or restructure of the
vice position to include how the department expects to fund the position if additional funds are required. See justification memorandum template - Section 3.
A current and proposed organizational chart of the subject department or division showing the location of the new or restructured position.
A draft of the proposed advertisement
13 April 2012 Page 2
RPA for AD Recruitment Actions Fact Sheet
• The CHR, Staffing & Classification Division, will review and process the RPA upon receipt.
Note: All RPAs must be signed and dated. RPAs received with incomplete or inaccurate information will be returned to the originator.
16 November 2012 Page 1
Fact Sheet
Staffing and Classificationof the Health Sciences, Civilian Human ResourcesUNIFORMED SERVICES UNIVERSITY
Request for Personnel Action (RPA) for Hiring Volunteer
The following provides guidance and information on the appropriate documentation needed to initiate a volunteer recruitment action. Agencies must document service performed without compensation by persons who do not receive a Federal appointment and are required to inform volunteers of the nature of their appointments.
The department will prepare a Request for Personnel Action (RPA) for the recruitment action. See Section 3 for sample forms and guidance. Indicate the Not to Exceed (NTE) date of no more than one (1) year on Block 1-
“Action Requested” of the RPA. The RPA must be signed and dated by the immediate supervisor and authorized by
the appropriate Chair, Department/Activity Head, or higher level official in the chain of command.
The RPA must be submitted at least seven (7) working days prior to entrance on
duty (EOD) to provide sufficient time to coordinate the action with the appropriate USU departments (i.e. Security, Environmental Health & Occupational Safety, and the Learning Resources Center).
CHR, Staffing & Classification Division, will coordinate the entrance on duty date (EOD). All RPAs received must be signed and dated. RPAs with incomplete or inaccurate information will be returned to the originator.
The following completed documents are required and must accompany the RPA:
Form DD-2793 (Volunteer Agreement), Parts I and II, http://www.usuhs.mil/chr/doc/DD‐
2793.pdf. See Section 3, Forms and Guidance.
A copy of the volunteer’s resume/cv.
Submit the completed RPA, DD-2793, and resume/cv to CHR.
FOR MINORS
If the volunteer is a minor (17 or younger), the following additional documents will be required and must accompany the RPA:
16 November 2012 Page 2
RPA for Hiring a Volunteer Fact Sheet
Work Permit Application along with proof of age document. See Section 3, Forms and Guidance. The CHR must receive the individual’s work permit before employment begins.
Permission from the school the volunteer is presently attending. Permission from the school is only required during the school year. If required, the letter must be on school’s letterhead.
Parental Permission Statement (signed and dated). See Section 3, Forms and Guidance.
USUHS Form 6050- Work Assignment for a Minor. See Section 3, Forms and Guidance.
If the volunteer is below 16 years of age, an exception to the age requirement
must be approved by Environmental Health & Occupational Safety (EHS). See Section 3, Forms and Guidance.
Minors working in Laboratories: Minors younger than 16 will not be allowed to
work in “posted” laboratories. Minors between the ages of 16 and 18 may be allowed to work in “posted” laboratories with the permission of the USUHS Radiation Safety Officer (RSO), 301-295-3390. See Section 3, Forms and Guidance.
EXTENDING VOLUNTEER APPOINTMENTS
The department will prepare an RPA to request an “Extension of Appointment” and indicate the new Not to Exceed (NTE) date. The NTE date may not be more than one year.
The RPA must state the reason/rationale for extension in Part D, Remarks by the requesting office.
The RPA must be signed and dated by the immediate supervisor and authorized by the appropriate Chair, Department/Activity Head, or higher level official in the chain of command.
Submit the RPA (Request for Extension) to CHR at least 30 days prior to the expiration of the original appointment.
IN-PROCESSING PROCEDURES
Volunteers will report to Civilian Human Resources (CHR), Building A, room A1022.
16 November 2012 Page 3
Fact Sheet
Staffing and ClassificationRPA for Hiring a Volunteer Fact Sheet
CHR will in-process volunteer personnel only on Mondays (10:00 to 11:00 A.M.) and Wednesdays (9:00 to 10:00 A.M.). All EODs must be coordinated with CHR at least 7 working days prior to the effective date.
Volunteers are required to provide one the following valid forms of identification during
in-processing. Expired documents will not be accepted.
U.S. Citizens: Birth Certificate, U.S. Passport, or Social Security Card with a valid Driver’s License or State ID.
Non-U.S. Citizens: Permanent Resident Card (green card), Employment Authorization Card or VISA authorizing permission to work in the U.S.
Volunteers will receive a CHR check-in sheet for reporting to the departments listed
below:
USUHS/AFRRI Security Office
USUHS Environmental Health & Occupational Safety Office (EHS)
Volunteers must return the check-in sheet to the CHR. Failure to return the form will relieve USUHS of any responsibility for the volunteer.
OUT-PROCESSING PROCEDURES
All Volunteers must out-process through CHR at least 3 work days prior to the end of their service.
The supervisor of the volunteer employee must complete Part IV of Form DD-2793 (Volunteer Agreement) at the end of the volunteer employee’s service and return the form to CHR.
ADDITIONAL INFORMATION CONCERNING VOLUNTEER EMPLOYMENT
Volunteers may not supervise paid employees or military personnel.
Volunteers may not be used to displace paid employees, or in lieu of filling authorized paid personnel positions.
Volunteers are considered employees of the Federal government only for the following purposes:
Concerning compensation for the disability or death of an employee resulting from
personal injury sustained while in the performance of his/her duty.
16 November 2012 Page 4
RPA for Hiring a Volunteer Fact Sheet
Regarding the maintenance of records on individuals that are contained in a Privacy Act system of records.
Criminal laws relating to conflicts of interest (18 U.S., Chapter 11). Defense of certain suits arising out of alleged legal malpractice under Title 10
U.S.C. 1054
The CHR will retain volunteer records for three (3) years following the termination of volunteer service.
Any questions regarding volunteer appointments should be addressed to the CHR, Staffing and Classification Division, at (301) 295-3412.
26 August 2013 Page 1
Fact Sheet Staffing and Classification
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Recruitment Instructions for Administratively Determined Search Committees
The following provides instructions and guidance for conducting a recruitment search for an Administratively Determined (AD) position. Management officials who plan to establish a recruitment search committee and appointed search committee Chairs should consult with their designated CHR Staffing & Classification Specialist to discuss search committee guidelines before starting the search process. A. Establishing a Recruitment Search Committee
1. When an AD position is approved for recruitment, the appropriate organization management official may establish and charge a recruitment search committee to review and recommend candidates for the position to be filled (Note: a recruitment search committee is not required for faculty positions below the rank of Associate Professor). The search committee will be established in accordance with the applicable USUHS School or College policies and procedures and USUHS Instruction 1107A. All recruitment search committees must be established appropriately to ensure a valid search.
2. A recruitment search committee will consist of only active Federal Government civilian
and/or military employees. Non-government personnel may not serve as a recruitment search committee member for a Government position.
3. A recruitment search committee will consist of the minimum number of members
specified in USUHS Instruction 1107A or the applicable USUHS School or College policies.
4. The appropriate management official will appoint a Chair of the recruitment search committee. The Chair will manage the activities of the search committee and ensure that the committee adheres to the charge and to USUHS and Government regulations, policies, and procedures.
5. The appointed search committee members should be subject matter experts and/or
knowledgeable in the field or specialty area or functions of the position being filled. All search committee members must be recorded on the Search Committee Member Roster (attachment 1) and submitted to the CHR for review prior to starting the search process.
6. The search committee will recommend and submit a minimum of two candidates to the
selecting official for consideration, except in unusual circumstances (e.g., only one candidate applied for the position to be filled).
26 August 2013 Page 2
Recruitment Instructions for Administratively Determined Search Committees Fact Sheet
B. Search Committee Guidelines
1. All search committees will conduct recruitment searches in accordance with USUHS
and Government procedures and guidelines, and the procedures specified in the charge, to include the following:
a. Convene and start reviewing applications received from candidates after the
position has been appropriately posted and opened in HigherEdJobs.com by the CHR.
b. Comply with Equal Employment Opportunity (EEO) and affirmative action policies and merit principles (attachment 2). All recruitment and appointment actions taken will be designed to provide fair and equal employment consideration to all qualified candidates without regard to age, citizenship, national origin, marital status, race, religion, sex, or handicapping condition.
c. Comply with provisions of confidentiality and privacy. Search committee
members will not discuss candidates or aspects of committee discussions with any individual who does not have a bona fide need to know the information. Committee members will sign a confidentiality agreement to serve on the committee. Committee members will also not release any privacy act information concerning a candidate to any individual who does not have an official business need for the information.
d. Follow the established steps in the recruitment and recommendation process. e. Adhere to the projected time lines for completing the recruitment process steps.
f. Examine special qualifications required for the position, if necessary. The source
and number of recommendations regarding candidates’ qualifications acquired from individuals both within and outside the USUHS schools and others knowledgeable in the area will be defined in the charge to the committee or as defined in the respective USUHS School or College policies and/or guidelines.
g. For certain AD positions, the search committee will be established and charged
to serve as an ad hoc committee equivalent to the school’s CAPT for the recruitment of these permanent positions. Consult with the CHR, Staffing and Classification Division, to ensure appropriate composition of the ad hoc CAPT committee.
2. Candidate Review Process. The search committee will develop appropriate screening
and evaluation criteria and methods to evaluate candidates based upon the committees’ review of the position being filled and apply it consistently throughout the search process. The search committee must:
a. Record all candidates that applied for the position on the Applicant Roster (attachment 3).
26 August 2013 Page 3
Staffing and Classification Recruitment Instructions for Administratively Determined Search Committees Fact Sheet
b. Agree on methods for grouping candidates based on the established screening and evaluation criteria.
c. Agree on a uniform structure for candidate evaluation by interviewers and apply
it consistently throughout the interview process. All candidates must be evaluated by the same criteria, asked the same type qualification or work experience questions related to the position to be filled, and provided the same treatment.
d. Evaluate all candidates based on their written application package and any
additional information obtained from the candidates during the search process to include references supplied by the candidate or references contacted by the search committee through the formal interview or reference check processes. Information that is not a part the written application package or not received through the formal interview or reference check processes should not be considered regarding a candidate by the committee during the search process.
e. Conduct all interviews using the same process for each candidate that is invited
for an interview.
f. Ensure that committee actions and recommendations are made in accordance with established USUHS EEO and affirmative action policies and procedures and merit principles.
g. Except in unusual circumstances, recommend and submit a minimum of two
candidates for selection to the selecting official for consideration using the AD Referral and Selection Certificate (attachment 4) along with the candidates’ curriculum vitaes (CV) and the committees’ feedback on the candidates if any.
h. The selecting official will return the selection certificate to the Chair of the
search committee when he or she has made a determination. 3. Recruitment and Selection Documentation for CHR
a. After the selection of a candidate, the committee Chair will coordinate the action
with the CHR and provide a copy of all necessary documentation for the CHR recruitment case file to include documents a, c, f, g, and h listed below in Section 4.
4. Maintenance of Recruitment Records. The search committee must complete and
maintain the following records:
a. The names of all search committee members and composition (title, gender, and national origin for each member) using the Search Committee Member Roster (attachment 1).
b. A copy of the advertisement.
26 August 2013 Page 4
Recruitment Instructions for Administratively Determined Search Committees Fact Sheet
c. A list of all candidates that applied for the position (Applicant Roster - attachment 3).
d. A copy of all candidate’s curriculum vitae or resumes that applied.
e. The established evaluation criteria and the evaluation/scoring documents on the
candidates if used. f. The list of all candidates who were interviewed.
g. The names of the candidates referred for final selection (AD Referral and
Selection Certificate - attachment 4).
h. The name of the candidate selected for the position and a copy of his or her CV or resume.
i. The search committee Chair will assemble all the documentation from the search
and provide it to the respective department. Departments and/or Program Directors are required to maintain the recruitment package and the above records for each recruitment action for two (2) years from the date the selected candidate begins employment.
For Official Use Only Revised 8-26-2013
UNIFORMED SERVICES UNIVERSITY Of the Health Sciences
Attachment 1
Search Committee Member Roster
Date Established:
Vacant Position Title:
Tenure Status:
Department:
Committee Chair:
Name Department Title Gender Race Signature
UNIFORMED SERVICES UNIVERSITY Of the Health Sciences
Attachment 2
Merit System Principles
The Merit Principles listed below are adapted from the statutory language that appears in section 2301(b) of title 5, United States Code.
Recruit qualified individuals from all segments of society and select and advance employees on the basis of merit after fair and open competition.
Treat employees and applicants fairly and equitably, without regard to political affiliation, race, color, religion, national origin, sex, marital status, age, or handicapping condition.
Provide equal pay for equal work and reward excellent performance.
Maintain high standards of integrity, conduct, and concern for public interest.
Manage employees efficiently and effectively.
Retain or separate employees on the basis of their performance.
Educate and train employees when it will result in better organizational or individual performance.
Protect employees from improper political influence.
Protect employees against reprisal for the lawful disclosure of information in "whistleblower" situations (i.e., protect people who report things like illegal and/or wasteful activities).
For Official Use Only Revised 8-26-2013
UNIFORMED SERVICES UNIVERSITY Of the Health Sciences
Attachment 3
Applicant Roster
Department:
Position Title:
Tenure Status:
Date Opened:
Date Closed:
Name Date Application Received Gender Race Not Qualified Qualified Best Qualified
Interviewed Yes No
Administratively Determined (AD) Referral and Selection Certificate
For Official Use Only 8-26-2013
Attachment 4
Date: RPA Number:
Department: Duty Location:
Position Title/Series: Committee Chair:
Tenure Status:
Selection Certificate Notes
1. The selecting official or his/her designee is responsible for answering inquiries regarding the job-related criteria used to select among the candidates referred on this certificate. It is recommended that you retain sufficient information regarding the selection methods used to enable you to answer requested inquires. 2. The candidates listed below were evaluated by an appointed USUHS Search Committee and were found to be the best qualified candidates for this position. Any candidate on this list may be interviewed. 3. Except in unusual circumstances, the search committee will refer a minimum of two candidates. 4. Any candidate on the list may be selected. Annotate the certificate below by checking the appropriate box “selected”, “not selected” or “alternate selection.” 5. The referred candidate(s) CV and any other relevant information are attached for your review and consideration. 6. This certificate is valid for 90 calendar days after the date it is signed to allow for the selection official to make another department selection. This certificate is only valid for positions in the same department with the same title and tenure status as cited above. 7. This certificate must be returned to Civilian Human Resources (CHR) upon completion.
Candidate’s Name Selected Not Selected Alternate Selection
Selecting Official Signature Date Print Name, Title and Phone Number
24 September 2013 Page 1
Fact Sheet Staffing and Classification
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Establish an Administratively Determined (AD) Position Description
The following provides guidance and information on how to establish and write a job description for USUHS AD positions. Positions covered under the University’s AD system include Instructors, Assistant, Associate, and full Professors, President, Deans, Assistant and Associate Deans, Vice Presidents, Assistant Vice Presidents, Executive Assistants, Research Associates, Senior Research Associates, and Postdoctoral Fellows.
• Departments should consult with their designated CHR Staffing & Classification Specialist to discuss the process of establishing an AD position description (PD) prior to writing the PD.
• Draft a narrative PD which includes the information described under the following paragraph headings. Sample PDs, see Section 3.
I. Introduction - At a minimum, the introduction should include: USU mission statement. Department mission statement. The organizational location of the position.
II. Major Duties - A statement of the important, regular, and recurring duties and
responsibilities of the position. State the essential, regular, and recurring duties and responsibilities assigned the
position. Only significant duties & responsibilities should be described. Describe the critical duties in separate paragraphs, i.e. teaching, research, clinical
services, administrative duties, supervision, etc. A major duty is paramount to the position and generally constitutes a majority of
the employee’s time.
III. Supervisory Controls State to whom the position reports. Describe how the work is assigned and evaluated.
IV. Qualification Requirements - Include the required qualifications of the
position as described below. (Note: See USU Instruction 1100, SOM Procedures, Enclosure 3, GSN Procedures, Enclosure 4, SOM DPM-001-06 (dated 9 March 2006), or GSN Policies & Procedures 2009-01 (dated 30 September 2009) for University faculty and academic staff minimum qualification requirements)
24 September 2013 Page 2
RPA for Establishing an AD Position Description Fact Sheet
Earned degree (M.D., Ph.D., D.O., etc.) Experience, knowledge, skills, certifications, licenses, etc. The qualification requirements must also include one of the below statements for
AD faculty positions:
o The successful candidate must be academically qualified for a faculty appointment at the Professor level in accordance with USUHS academic policies.
o The successful candidate must be academically qualified for a faculty appointment at the Associate Professor level in accordance with USUHS academic policies.
o The successful candidate must be academically qualified for a faculty appointment at the Assistant Professor level in accordance with USUHS academic policies.
V. Other Position Factors - A statement describing other below important elements of
the position. Please annotate as appropriate. Tenure Status: This position is tenured. This position is in the tenure eligible track. This position is in the tenure ineligible track. Position Sensitivity Level: The position does not require a secret clearance. The position requires a secret clearance. The incumbent must be able to obtain and
maintain a secret security clearance. Note: Check block 12 on Form OF- 8 (PD cover sheet) as applicable.
Patient Care/Drug Testing Requirement:
When applicable add: This position will be subject to pre-employment and random
drug testing under the USUHS Drug-Free Workplace Program. For Chair and Administrator Positions Only: When applicable add: Assignment as Chairperson is an administrative assignment
and is without tenure. This assignment is for a five-year term and may be renewed with no limit on the number of renewals. Assignment as Chairperson is not a continuous appointment and as such the incumbent serves at the pleasure of his or her immediate supervisor(s) and may be relieved as Chair at any time.
When applicable add: The incumbent of this position may perform faculty responsibilities such as teaching, research, and/or patient care as an integral part of their responsibilities.
24 September 2013 Page 3
Staffing and Classification RPA for Establishing an AD Position Description Fact Sheet
For Administrator Positions Only: When applicable add: Assignment as job tile is an administrative assignment and
is without tenure. This assignment is for a five-year term and may be renewed with no limit on the number of renewals. Assignment as job tile is not a continuous appointment and as such the incumbent serves at the pleasure of their immediate supervisor(s) and may be relieved as job tile at any time.
When applicable add: The incumbent of this position may also hold a USUHS faculty appointment and may perform faculty responsibilities such as teaching, research, and/or patient care as an integral part of their responsibilities.
Note: Sample Forms & Guidance:
Sample RPA for Establishing an AD Position Description – See Section 2.
Sample Position Descriptions (Chairperson, Full Professor, Associate Professor, Assistant Professor, Research Associate, and Post-Doctoral Fellow) - See Section 3.
Sample Form, OF-8 - See Section 3 USUHS 1100, SOM Procedures, Enclosure 3,
http://www.usuhs.mil/asd/instructions/1100.pdf - See Section 3 GSN Procedures, Enclosure 4,
http://www.usuhs.edu/asd/instructions/1100GSN.pdf - See Section 3 Enclosure 4, SOM DPM-001-06 (dated 9 March 2006) - See Section 3 GSN Policies & Procedures 2009-01 (dated 30 September 2009) - See
Section 3
Sample RPA for GS/FWS Recruitment Actions
Standard Form 52 Rev. 7/91 U.S. Office of Personnel Management FPM Supp. 296-33, Subch. 3
CONTINUED ON REVERSE SIDE 52-118
Editions Prior to 7/91 Are Not Usable After 6/30/93 NSN 7540-01-333-6239
OVER
REQUEST FOR PERSONNEL ACTION PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
Recruit/Fill – New (or) Vice Jane Doe (include employee’s name on vice actions) 2. Actions Requested
MED-11-001 3. For Additional Information Call (Name and Telephone Number)
John Doe, (301) 295-1234 4. Proposed Effective Date
1 June 2011 5. Action Requested By (Typed Name, Title, Signature, and Request Date)
Immediate Supervisor, Director of ___, MED & Date 6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Authorizing Official, Chairperson, MED & Date PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
3. Date of Birth
4. Effective Date
FIRST ACTION SECOND ACTION 5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
15. TO: Position Title and Number
Program Specialist PD# F444A
8. Pay Plan
9. Occ. Plan
10. Grade or Level
11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay Plan
GS
17. Occ. Code
0301
18. Grade or Level
11 19. Step or Rate
20. Total Salary
21. Pay Basis
12A. Basic Pay
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
20A. Basic Pay
20B. Locality Adj.
20C. Adj. Basic Pay
20D. Other Pay
14. Name and Location of Position’s Organization
22. Name and Location of Position’s Organization
USUHS, School of Medicine Department of Medicine, Nephrology Division Bethesda, Maryland
EMPLOYEE DATA
23. Veterans Preference 1- None 3- 10-Point/Disability 5- 10-Point/Other 2- 5-Point 4- 10-Point/Compensable 6- 10-Point/Compensable/30%
24. Tenure
0- None 2- Conditional 1- Permanent 3- Indefinite
25. Agency Use
26. Veterans Pref for RIF
YES NO
27. FEGLI 28. Annuitant Indicator 29. Pay Rate Determinant
30. Retirement Plan 31. Service Comp. Date (leave)
32. Work Schedule 33. Part-Time Hours Per
F Biweekly Pay Period
POSITION DATA
34. Position Occupied 35. FLSA Category 36. Appropriation Code
37. Bargaining Unity Status
1 1- Competitive Service 3- SES General 2- Excepted Service 4- SES Career E- Exempt
N- Nonexempt
38. Duty Station Code
39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD 40. Agency
41.
DDAAFD
42.
1BICDG
43.
1BICDG
44.
45. Educational Level
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship 50. Veterans Status 51. Supervisory Status
1- USA 8 - Other PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function Initials/Signature Date Office/Function Initials/Signature Date
A. D.
B. E.
C. F. 2. Approval: I certify that the information entered on this form is accurate and that the proposed action is in compliance with statutory and regulatory requirements.
Signature Approval Date
Sample RPA for GS/FWS Recruitment Actions
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement? If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
YES NO
PART E – Employee Resignation/Retirement
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding address. Your reason may be considered in any future decision regarding your re-employment in the Federal service and may also be used to determine your eligibility for umemployment compensation benefits. Your forwarding address will be used primarily to mail you copies of any documents you should have or any pay or compensation to which you are entitled. This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and their records, while section 8506 requires agencies to furnish the specific reason for termination of Federal service to the Secretary of Labor or a State agency in connection with administration of unemployment compensation programs. The furnishing of the information is voluntary; however, failure to provide it my result in your not receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you; and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at the end of the day – midnight – unless you specify otherwise.)
2. Effective Date 3. Your Signature 4. Date Signed 5. Forwarding Address (Number, Street, City, State, ZIP Code)
PART F – Remarks for SF 50
Sample RPA for GS/FWS Reassignment Actions
Standard Form 52 Rev. 7/91 U.S. Office of Personnel Management FPM Supp. 296-33, Subch. 3
CONTINUED ON REVERSE SIDE 52-118
Editions Prior to 7/91 Are Not Usable After 6/30/93 NSN 7540-01-333-6239
OVER
REQUEST FOR PERSONNEL ACTION PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
Reassignment 2. Actions Requested
MED-11-001 3. For Additional Information Call (Name and Telephone Number)
JOHN DOE, (301) 295-1234 4. Proposed Effective Date
1 June 2011 5. Action Requested By (Typed Name, Title, Signature, and Request Date)
Immediate Supervisor, DVM, Director, MED & Date 6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Authorizing Official, Chair Person, DVM, MED & Date PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
Doe, Jane 2. Social Security Number
3. Date of Birth
4. Effective Date
FIRST ACTION SECOND ACTION 5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
Security Assistant PD#A2913
15. TO: Position Title and Number
Security Assistant (OA) PD# F444A
8. Pay Plan
GS 9. Occ. Plan
080 10. Grade or Level
11 11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay Plan
GS
17. Occ. Code
080
18. Grade or Level
11 19. Step or Rate
20. Total Salary
21. Pay Basis
12A. Basic Pay
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
20A. Basic Pay
20B. Locality Adj.
20C. Adj. Basic Pay
20D. Other Pay
14. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine Department of Medicine, Digestive Diseases Division Bethesda, Maryland
22. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine Department of Medicine, Nephrology Division Bethesda, Maryland
EMPLOYEE DATA
23. Veterans Preference 1- None 3- 10-Point/Disability 5- 10-Point/Other 2- 5-Point 4- 10-Point/Compensable 6- 10-Point/Compensable/30%
24. Tenure
0- None 2- Conditional 1- Permanent 3- Indefinite
25. Agency Use
26. Veterans Pref for RIF
YES NO
27. FEGLI 28. Annuitant Indicator 29. Pay Rate Determinant
30. Retirement Plan 31. Service Comp. Date (leave)
32. Work Schedule 33. Part-Time Hours Per
F Biweekly Pay Period
POSITION DATA
34. Position Occupied 35. FLSA Category 36. Appropriation Code
37. Bargaining Unity Status
1 1- Competitive Service 3- SES General 2- Excepted Service 4- SES Career E- Exempt
N- Nonexempt
38. Duty Station Code
39. Duty Station (City – Count – State or Overseas Location)
40. Agency
41.
DDAAFD
42.
1BICDG
43.
1BICDG
44.
45. Educational Level
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship 50. Veterans Status 51. Supervisory Status
1- USA 8 - Other PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function Initials/Signature Date Office/Function Initials/Signature Date
A. D.
B. E.
C. F. 2. Approval: I certify that the information entered on this form is accurate and that the proposed action is in compliance with statutory and regulatory requirements.
Signature Approval Date
Sample RPA for GS/FWS Reassignment Actions
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement? If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
YES NO
PART E – Employee Resignation/Retirement
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding address. Your reason may be considered in any future decision regarding your re-employment in the Federal service and may also be used to determine your eligibility for umemployment compensation benefits. Your forwarding address will be used primarily to mail you copies of any documents you should have or any pay or compensation to which you are entitled. This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and their records, while section 8506 requires agencies to furnish the specific reason for termination of Federal service to the Secretary of Labor or a State agency in connection with administration of unemployment compensation programs. The furnishing of the information is voluntary; however, failure to provide it my result in your not receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you; and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at the end of the day – midnight – unless you specify otherwise.)
2. Effective Date 3. Your Signature 4. Date Signed 5. Forwarding Address (Number, Street, City, State, ZIP Code)
PART F – Remarks for SF 50
Sample RPA for GS/FWS Career-Ladder Promotion
Standard Form 52 Rev. 7/91 U.S. Office of Personnel Management FPM Supp. 296-33, Subch. 3
CONTINUED ON REVERSE SIDE 52-118
Editions Prior to 7/91 Are Not Usable After 6/30/93 NSN 7540-01-333-6239
OVER
REQUEST FOR PERSONNEL ACTION PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
Career-Ladder Promotion 2. Actions Requested
MED-11-001 3. For Additional Information Call (Name and Telephone Number)
JOHN DOE, (301) 295-1234 4. Proposed Effective Date
1 June 2011 5. Action Requested By (Typed Name, Title, Signature, and Request Date)
Immediate Supervisor, DVM, Director, MED & Date 6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Authorizing Official, Chair Person, DVM, MED & Date PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
Doe, Jane 2. Social Security Number
3. Date of Birth
4. Effective Date
FIRST ACTION SECOND ACTION 5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
Security Assistant (OA) PD# F444B
15. TO: Position Title and Number
Security Assistant (OA) PD# F444A
8. Pay Plan
GS 9. Occ. Plan
080 10. Grade or Level
09 11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay Plan
GS
17. Occ. Code
080
18. Grade or Level
11 19. Step or Rate
20. Total Salary
21. Pay Basis
12A. Basic Pay
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
20A. Basic Pay
20B. Locality Adj.
20C. Adj. Basic Pay
20D. Other Pay
14. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine Department of Medicine, Nephrology Division Bethesda, Maryland
22. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine Department of Medicine, Nephrology Division Bethesda, Maryland
EMPLOYEE DATA
23. Veterans Preference 1- None 3- 10-Point/Disability 5- 10-Point/Other 2- 5-Point 4- 10-Point/Compensable 6- 10-Point/Compensable/30%
24. Tenure
0- None 2- Conditional 1- Permanent 3- Indefinite
25. Agency Use
26. Veterans Pref for RIF
YES NO
27. FEGLI 28. Annuitant Indicator 29. Pay Rate Determinant
30. Retirement Plan 31. Service Comp. Date (leave)
32. Work Schedule 33. Part-Time Hours Per
F Biweekly Pay Period
POSITION DATA
34. Position Occupied 35. FLSA Category 36. Appropriation Code
37. Bargaining Unity Status
1 1- Competitive Service 3- SES General 2- Excepted Service 4- SES Career E- Exempt
N- Nonexempt
38. Duty Station Code
39. Duty Station (City – Count – State or Overseas Location)
40. Agency
41.
DDAAFD
42.
1BICDG
43.
1BICDG
44.
45. Educational Level
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship 50. Veterans Status 51. Supervisory Status
1- USA 8 - Other PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function Initials/Signature Date Office/Function Initials/Signature Date
A. D.
B. E.
C. F. 2. Approval: I certify that the information entered on this form is accurate and that the proposed action is in compliance with statutory and regulatory requirements.
Signature Approval Date
Sample RPA for GS/FWS Career-Ladder Promotion
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement? If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
YES NO
PART E – Employee Resignation/Retirement
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding address. Your reason may be considered in any future decision regarding your re-employment in the Federal service and may also be used to determine your eligibility for umemployment compensation benefits. Your forwarding address will be used primarily to mail you copies of any documents you should have or any pay or compensation to which you are entitled. This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and their records, while section 8506 requires agencies to furnish the specific reason for termination of Federal service to the Secretary of Labor or a State agency in connection with administration of unemployment compensation programs. The furnishing of the information is voluntary; however, failure to provide it my result in your not receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you; and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at the end of the day – midnight – unless you specify otherwise.)
2. Effective Date 3. Your Signature 4. Date Signed 5. Forwarding Address (Number, Street, City, State, ZIP Code)
PART F – Remarks for SF 50
Sample RPA for AD Recruitment Actions
Standard Form 52 Rev. 7/91 U.S. Office of Personnel Management FPM Supp. 296-33, Subch. 3
CONTINUED ON REVERSE SIDE 52-118
Editions Prior to 7/91 Are Not Usable After 6/30/93 NSN 7540-01-333-6239
OVER
REQUEST FOR PERSONNEL ACTION PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
Recruit/Fill - New or Vice (if vice include employee’s) (tenure track or non-tenured track) 2. Actions Requested
SUR-12-001 3. For Additional Information Call (Name and Telephone Number)
Jane Doe (301) 295-1234 4. Proposed Effective Date
ASAP 5. Action Requested By (Typed Name, Title, Signature, and Request Date)
John Doe, Chair, Department of Surgery 6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Jim Doe, Dean, School of Medicine PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
3. Date of Birth
4. Effective Date
FIRST ACTION SECOND ACTION 5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
15. TO: Position Title and Number
Associate Professor PD #1234
8. Pay Plan
9. Occ. Plan
10. Grade or Level
11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay Plan
AD
17. Occ. Code
602
18. Grade or Level
00 19. Step or Rate
00 20. Total Salary
21. Pay Basis
PA 12A. Basic Pay
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
20A. Basic Pay
20B. Locality Adj.
20C. Adj. Basic Pay
20D. Other Pay
14. Name and Location of Position’s Organization
22. Name and Location of Position’s Organization
USUHS, School of Medicine Department of Surgery, Cardiology Division Bethesda, MD
EMPLOYEE DATA
23. Veterans Preference 1- None 3- 10-Point/Disability 5- 10-Point/Other 2- 5-Point 4- 10-Point/Compensable 6- 10-Point/Compensable/30%
24. Tenure
0- None 2- Conditional 1- Permanent 3- Indefinite
25. Agency Use
26. Veterans Pref for RIF
YES NO
27. FEGLI 28. Annuitant Indicator 29. Pay Rate Determinant
30. Retirement Plan 31. Service Comp. Date (leave)
32. Work Schedule 33. Part-Time Hours Per
F Biweekly Pay Period
POSITION DATA
34. Position Occupied 35. FLSA Category 36. Appropriation Code
37. Bargaining Unity Status
2 1- Competitive Service 3- SES General 2- Excepted Service 4- SES Career E- Exempt
N- Nonexempt
38. Duty Station Code
39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD 40. Agency
41.
DDAAFD 42.
1BICDG
43.
1BICDG 44.
45. Educational Level
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship 50. Veterans Status 51. Supervisory Status
1- USA 8 - Other PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function Initials/Signature Date Office/Function Initials/Signature Date
A. D.
B. E.
C. F. pproval: I certify that the information entered on this form is accurate and that the proposed action is in compliance with statutory and regulatory requirements.
Signature Approval Date
Sample RPA for AD Recruitment Actions
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement? If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
YES NO
PART E – Employee Resignation/Retirement
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding address. Your reason may be considered in any future decision regarding your re-employment in the Federal service and may also be used to determine your eligibility for umemployment compensation benefits. Your forwarding address will be used primarily to mail you copies of any documents you should have or any pay or compensation to which you are entitled. This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and their records, while section 8506 requires agencies to furnish the specific reason for termination of Federal service to the Secretary of Labor or a State agency in connection with administration of unemployment compensation programs. The furnishing of the information is voluntary; however, failure to provide it my result in your not receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you; and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at the end of the day – midnight – unless you specify otherwise.)
2. Effective Date 3. Your Signature 4. Date Signed 5. Forwarding Address (Number, Street, City, State, ZIP Code)
PART F – Remarks for SF 50
Sample RPA for Hiring Volunteers Standard Form 52
Rev. 7/91 U.S. Office of Personnel Management FPM Supp. 296-33, Subch. 3
CONTINUED ON REVERSE SIDE 52-118
Editions Prior to 7/91 Are Not Usable After 6/30/93 NSN 7540-01-333-6239
OVER
REQUEST FOR PERSONNEL ACTION PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
Volunteer NTE 12/23/2012 2. Actions Requested
3. For Additional Information Call (Name and Telephone Number)
Point of Contact 4. Proposed Effective Date
16-JUL-2012 5. Action Requested By (Typed Name, Title, Signature, and Request Date)
Supervisor or Department Head 6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Next higher level official PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
Doe, John 2. Social Security Number
000-00-0000 3. Date of Birth
00/00/0000 4. Effective Date
FIRST ACTION SECOND ACTION 5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
15. TO: Position Title and Number
VOLUNTEER
8. Pay Plan
9. Occ. Plan
10. Grade or Level
11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay Plan
17. Occ. Code
18. Grade or Level
19. Step or Rate
20. Total Salary
0.00 21. Pay Basis
12A. Basic Pay
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
20A. Basic Pay
20B. Locality Adj.
20C. Adj. Basic Pay
20D. Other Pay
14. Name and Location of Position’s Organization
22. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine Department Name
EMPLOYEE DATA
23. Veterans Preference 1- None 3- 10-Point/Disability 5- 10-Point/Other 2- 5-Point 4- 10-Point/Compensable 6- 10-Point/Compensable/30%
24. Tenure
0- None 2- Conditional 1- Permanent 3- Indefinite
25. Agency Use
26. Veterans Pref for RIF
YES NO
27. FEGLI 28. Annuitant Indicator 29. Pay Rate Determinant
30. Retirement Plan 31. Service Comp. Date (leave)
32. Work Schedule 33. Part-Time Hours Per
Biweekly Pay Period
POSITION DATA
34. Position Occupied 35. FLSA Category 36. Appropriation Code
37. Bargaining Unity Status
1- Competitive Service 3- SES General 2- Excepted Service 4- SES Career E- Exempt
N- Nonexempt
38. Duty Station Code
39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD 40. Agency
41.
42.
43.
44.
45. Educational Level
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship 50. Veterans Status 51. Supervisory Status
1- USA 8 - Other PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function Initials/Signature Date Office/Function Initials/Signature Date
A. D.
B. E.
C. F. 2. Approval: I certify that the information entered on this form is accurate and that the proposed action is in compliance with statutory and regulatory requirements.
Signature Approval Date
Sample RPA for Hiring Volunteers
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement? If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
YES NO
PART E – Employee Resignation/Retirement
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding address. Your reason may be considered in any future decision regarding your re-employment in the Federal service and may also be used to determine your eligibility for umemployment compensation benefits. Your forwarding address will be used primarily to mail you copies of any documents you should have or any pay or compensation to which you are entitled. This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and their records, while section 8506 requires agencies to furnish the specific reason for termination of Federal service to the Secretary of Labor or a State agency in connection with administration of unemployment compensation programs. The furnishing of the information is voluntary; however, failure to provide it my result in your not receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you; and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at the end of the day – midnight – unless you specify otherwise.)
2. Effective Date 3. Your Signature 4. Date Signed 5. Forwarding Address (Number, Street, City, State, ZIP Code)
PART F – Remarks for SF 50
Sample RPA for Establishing AD Position Description
F
2
Standard Form 52 Rev. 7/91 U.S. Office of Personnel Management FPM Supp. 296-33, Subch. 3
REQUEST FOR PERSONNEL ACTION
PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.) 1. Actions Requested
Establish Position 2. Actions Requested
SUR-12-001 3. For Additional Information Call (Name and Telephone Number)
Jane Doe (301) 295-1234 4. Proposed Effective Date
ASAP 5. Action Requested By (Typed Name, Title, Signature, and Request Date)
John Doe, Chair, Department of Surgery 6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Jim Doe, Dean, School of Medicine PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.) 1. Name (Last, First, Middle) 2. Social Security Number 3. Date of Birth 4. Effective Date
FIRST ACTION SECOND ACTION 5-A. Code 5-B. Nature of Action 6-A. Code 6-B. Nature of Action
5-C. Code 5-D. Legal Authority 6-C. Code 6-D. Nature of Action
5-E. Code 5-F. Legal Authority 6-E. Code 6-F. Nature of Action
7. FROM: Position Title and Number 15. TO: Position Title and Number
Associate Professor PD #TBD
8. Pay Plan 9. Occ. Plan 10. Grade or Level 11. Step or Rate 12. Total Salary 13. Pay Basis 16. Pay
Plan
AD
17. Occ. Code
602
18. Grade or Level
00 19. Step or Rate
00 20. Total Salary 21. Pay
Basis
PA 12A. Basic Pay 12B. Locality Adj. 12C. Adj. Basic Pay 12D. Other Pay 20A. Basic Pay 20B. Locality Adj. 20C. Adj. Basic Pay 20D. Other Pay
14. Name and Location of Position’s Organization 22. Name and Location of Position’s Organization
USUHS, School of Medicine Department of Surgery, Cardiology Division
EMPLOYEE DATA 23. Veterans Preference 1- None 3- 10-Point/Disability 5- 10-Point/Other
2- 5-Point 4- 10-Point/Compensable 6- 10-Point/Compensable/30%
24. Tenure
0- None 2- Conditional 1- Permanent 3- Indefinite
25. Agency Use 26. Veterans Pref for RIF
YES NO
27. FEGLI 28. Annuitant Indicator 29. Pay Rate Determinant
30. Retirement Plan 31. Service Comp. Date (leave) 32. Work Schedule 33. Part-Time Hours Per
Biweekly Pay Period
POSITION DATA 34. Position Occupied 35. FLSA Category 36. Appropriation Code 37. Bargaining Unity Status
1- Competitive Service 3- SES General 2- Excepted Service 4- SES Career
E- Exempt N- Nonexempt
38. Duty Station Code 39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD 40. Agency 41.
DDAAFD 42.
1BICDG 43.
1BICDG 44.
45. Educational Level 46. Year Degree Attained 47. Academic Discipline 48. Functional Class 49. Citizenship 50. Veterans Status 51. Supervisory Status
PART C – Reviews and Approvals (Not to be used by requesting office.)
1- USA 8 - Other
1. Office/Function Initials/Signature Date Office/Function Initials/Signature Date
A. D.
B. E.
C. F.
pproval: I certify that the information entered on this form is accurate and that the proposed action is in compliance with statutory and regulatory requirements.
Signature Approval Date
CONTINUED ON REVERSE SIDE 52-118
OVER Editions Prior to 7/91 Are Not Usable After 6/30/93
NSN 7540-01-333-6239
Sample RPA for Establishing AD Position Description
PART D – Remarks by Requesting Office YES
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement? NO
If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
The position is in the tenure eligible track or tenure ineligible track.
PART E – Employee Resignation/Retirement Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding address. Your reason may be considered in any future decision regarding your re-employment in the Federal service and may also be used to determine your eligibility for umemployment compensation benefits. Your forwarding address will be used primarily to mail you copies of any documents you should have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and their records, while section 8506 requires agencies to furnish the specific reason for termination of Federal service to the Secretary of Labor or a State agency in connection with administration of unemployment compensation programs.
The furnishing of the information is voluntary; however, failure to provide it my result in your not receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you; and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please b e specific and avoid generalizations. Your resignation/retirement is effective at the end of the day – midnight – unless you specify otherwise.)
2. Effective Date 3. Your Signature 4. Date Signed 5. Forwarding Address (Number, Street, City, State, ZIP Code)
PART F – Remarks for SF 50
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13 April 2012 Page 1
Instructions for Completing a Request of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
for Personnel Action (SF-52)
Part A Block #1. Action Requested - Type in the Action that you are requesting, e.g., Establish (Classify), Recruit, Reassignment, Realignment, Extension of Appointment, Resignation, Leave-Without-Pay, Name Change, etc. Block #2. Request Number - Each Department/Activity should assign a department Log Number to monitor/track each SF-52 submitted by the department /activity. For example - MED-11-001 (this represents the three letter department code, the fiscal year, and the number of action). Once the request is coordinated through appropriate departments and the FMG, the CHR will assign a request for personnel action (RPA) number to your SF-52 using the DCPDS system. Block #3. For Additional Information Call - Enter the name and telephone number of the Administrative Point of Contact, which would be the person who can furnish additional information, if required. Block #4. Proposed Effective Date - Enter the date the requesting office wants the action completed or annotate ASAP. Block #5. Action Requested By - Enter the name, title, signature, and date of the person requesting the action. Normally, this will be the immediate supervisor. Block #6. Action Authorized by - Enter the name, title, signature, and date of the person authorizing the action. This will be the appropriate Chairperson, the Department/Activity Head, or higher level official in the chain of command. Part B Block #15. Enter Position Title and PD Description Number if applicable. Block #16. Enter Pay Plan, e.g. AD, GS, WG, WL, etc. Block #17. Enter Occupational Code (position series), e.g. 0201, 0602, 0510, etc. Block #18. Enter Grade or Level, (5/6/7) etc. If the position is new, leave blank. The block will be completed by the CHR/HRSC. If the position is an AD position, it will be 00. Block #22. Enter the name and location of the position’s organization. Block #32. Enter the designated work schedule (i.e., F for full-time and P for part-time. If the position is part-time, enter the tour duty in Part D - Remarks by Requesting Official of the SF-52).
13 April 2012 Page 2
Instructions for Completing a Request for Personnel Action (SF-52)
Block #34. Enter the service the position falls under (i.e., competitive, excepted, etc). Block #41. Enter the UIC#. USUHS UIC # is DDAAFD. Block #42. Enter the Org Code (if known or leave blank), e.g. 1BICDG Block #43. Enter the Cost Code Center (if known), same number as your Org Code. *Note: Once the request is coordinated through appropriate departments and the FMG, the request will be submitted to the CHR and a request for personnel action (RPA) number will be assigned to your RPA using the DCPDS system.
POSITION DESCRIPTION (Please Read Instructions on the Back) 1. Agency Position No.
2. Reason for Submission
Redescription New Reestablishment Other
Explanation (Show any positions replaced)
3. Service
Hdqtrs. Field
4. Employing Office Location Bethesda, Maryland
5. Duty Station
6. OPM Certification No.
7. Fair Labor Standards Act
Exempt Nonexempt
8. Financial Statements Required
Executive Personnel Employment and Financial Disclosure Financial Interests
9. Subject to IA Action
Yes No 10. Position Status
Competitive Excepted (Specify in Remarks) SES (Gen.) SES (CR)
11. Position Is:
Supervisory Managerial Neither
12. Sensitivity 1-Non- 3-Critical
Sensitive Sensitive 2-Noncritical 4-Special
Sensitive Sensitive
13. Competitive Level Code 14. Agency Use
15. Classified/Graded by Official Title of Position Pay Plan Occupational Code Grade Initials Date a. U.S. Office of Personnel Management
b. Department, Agency or Establishment
c. Second Level Review
d. First Level Review
e. Recommended by Supervisor or Initiating Office
Position Title as applicable (Assistant Professor/Program Specialist/Supply Technician)
AD/GS/ WG
301
9 or 00 for AD)
16. Organizational Title of Position (if different from official title)
17. Name of Employee (if vacant, specify)
18. Department, Agency, or Establishment DoD, Uniformed Services University of the Health Sciences
c. Third Subdivision Cardiology Division
a. First Subdivision School of Medicine
d. Fourth Subdivision
b. Second Subdivision Department of Surgery
e. Fifth Subdivision
19. Employee Review - This is an accurate description of the major duties and responsibilities of my position.
Signature of Employee (optional)
20. Supervisory Certification. I certify that this is an accurate statement of the major duties and responsibilities of this position and its organizational relationships, and that the position is necessary to carry out Government functions for which I am responsible. This certification is made with the knowledge that
this information is to be used for statutory purposes relating to appointment and payment of public funds, and that false or misleading statements may constitute violations of such statutes or their implementing regulations.
a. Typed Name and Title of Immediate Supervisor
b. Typed Name and Title of Higher-Level Supervisor or Manager (optional)
Signature
ELECTRONICALLY SIGNED //S//
Date
Signature
ELECTRONICALLY SIGNED //S//
Date
21. Classification/Job Grading Certification. I certify that this position has been classified/graded as required by Title 5, U.S. Code, in conformance with standards published by the U.S. Office of Personnel Management or, if no published standards apply directly, consistently with most applicable published standards.
22. Position Classification Standards Used in Classifying/Grading Position
Typed Name and Title of Official Taking Action
Information for Employees. The standards, and information on their application, are available in the personnel office. The classification of the position may be reviewed and corrected by the agency or the U.S. Office of Personnel Management. Information on classification/job grading appeals, and complaints on exemption from FLSA, is available from the personnel office or the U.S. Office of Personnel Management.
Signature ELECTRONICALLY SIGNED
3/29/01
23. Position Review Initials Date Initials Date Initials Date Initials Date Initials Date a. Employee (optional) b. Supervisor c. Classifier 24. Remarks
25. Description of Major Duties and Responsibilities (See Attached) NSN 7540-00-634-4265 Previous Edition Usable 5008-106 OF 8 (Rev. 1-85)
U.S. Office of Personnel Management FPM Chapter 295
Optional Form 8 (BACK) (Revised 1/85)
Instructions for Completing Optional Form 8 POSITION DESCRIPTION
In order to comply with the requirements of FPM Chapter 295, subchapter 3, and other provisions of the FPM, agencies must complete the items marked by an asterisk. Agencies may determine what other items are to be used. *1. Enter position number used by the agency for control purposes.
See FPM Chapter 312, Subchapter 3. *2. Check one.
• "Redescription" means the duties and/or responsibilities of an existing position are being changed.
• "New" means the position has not previously existed. • "Reestablishment" means the position previously existed, but
had been cancelled. • "Other" covers such things as change in title or occupational
series without a change in duties or responsibilities. • The "Explanation" section should be used to show the
reason if "Other" is checked, as well as any position(s) replaced by position number, title, pay plan, occupational code, and grade.
3. Check one. *4. Enter geographical location by city and State (or if position is in a
foreign country, by city and country). *5. Enter geographical location if different from that of #4. 6. To be completed by OPM when certifying positions. (See Item 15
for date of OPM certification.) For SES and GS-16/18 positions and equivalent, show the position number used on OPM Form 1390 (e.g., DAES0012).
*7. Check one to show whether the incumbent is exempt or non-exempt
from the minimum wage and overtime provisions of the Fair Labor Standards Act. See FPM Chapter 551.
8. Check box if statement is required. See FPM Chapter 734 for the
Executive Personnel Financial Disclosure Report, SF 278. See FPM Chapter 735, Subchapter 4, for the Employment and Financial interests Statement.
9. Check one to show whether Identical Additional positions are
permitted. See FPM Chapter 312, Subchapter 4. Agencies may show the number of such positions authorized and/or established after the "Yes" block.
10. Check one. See FPM Chapter 212 for information on the competitive
service and FPM Chapter 213 for the excepted service. For a position in the excepted service, enter authority for the exception, e.g., "Schedule A-213.3102(d)" for Attorney positions excepted under Schedule A of the Civil Service Regulations. SES (Gen) stands for a General position in the Senior Executive Service, and SES (CR) stands for a Career Reserved position.
11. Check one.
• A "Supervisory" position is one that meets the requirements for a supervisory title as set forth in current OPM classification and job-grading guidance. Agencies may designate first-level supervisory positions by placing "1" or "1st" after "Supervisory."
• A "Managerial" position is one that meets the requirements for such a designation as set forth in current OPM classification guidance.
12. Check one to show whether the position is non-sensitive, non-critical
sensitive, critical sensitive, or special sensitive for security purposes. If this is an ADP position, write the letter "C" beside the sensitivity.
13. Enter competitive level code for use in reduction-in-force actions. See FPM Chapter 351.
14. Agencies may use this block for any additional coding requirement.
*15. Enter classification/job grading action.
• For "Official Title of Position," see the applicable classification or job grading standard. For positions not covered by a published standard, see the General Introduction to "Position Classification Standards," Section III, for GS positions, or FPM Supplement 512-1, "Job Grading System for Trades and Labor Occupations," Part 1, Section III.
• For "Pay Plan" code, see FPM Supplement 292-1, "Personnel Data Standards," Book III.
• For "Occupational Code," see the applicable standard; or, where no standard has been published, see the "Handbook of Occupational Groups and Series of Classes" for GS positions, or FPM Supplement 512-1, Part 3, for trades and labor positions. For all positions in scientific and engineering occupations, enter the two-digit functional classification code in parentheses immediately following the occupational code, e.g., "GS-1310(14)." The codes are listed and discussed in the General Introduction to "Position Classification Standards," Section VI.
16. Enter the organizational, functional, or working title if it differs from
the official title. 17. Enter the name of the incumbent. If there is no incumbent, enter
"vacancy." *18. Enter the organizational location of the position, starting with the
name of the department or agency and working down from there. 19. If the position is occupied, have the incumbent read the attached
description of duties and responsibilities. The employee's signature is optional.
*20. This statement normally should be certified by the immediate
supervisor of the position. At its option, an agency may also have a higher-level supervisor or manager certify the statement.
*21. This statement should be certified by the agency official who
makes the classification/job grading decision. Depending on agency regulations, this official may be a personnel office representative, or a manager or supervisor delegated classification/job grading authority.
22. Enter the position classification/job grading standard(s) used and
the date of issuance, e.g., "Mail and File, GS-305, May 1977." 23. Agencies are encouraged to review periodically each established
position to determine whether the position is still necessary and, if so, whether the position description is adequate and classification/job grading is proper. See FPM Letter 536-1 (to be incorporated into FPM Chapter 536). This section may be used as part of the review process. The employee's initials are optional. The initials by the supervisor and classifier represent recertifications of the statements in items #20 and #21 respectively.
24. This section may be used by the agency for additional coding
requirements or for any appropriate remarks. *25. Type the description on plain bond paper and attach to the form.
The agency position number should be shown on the attachment. See appropriate instructions for format of the description and for any requirements for evaluation documentation, e.g., "Instructions for the Factor Evaluation System," in the General Introduction to "Position Classification Standards," Section VII.
Recruitment Checklist
13 April 2012
of the Health Sciences, Civilian Human Resources UNIFORMED SERVICES UNIVERSITY
Recruitment Checklist
Please provide the information below with your Recruitment Request for Personnel Action (RPA). This information identifies key elements that are essential to proceed with your recruitment action.
POSITION TO BE FILLED RPA# Title, PP/Ser/Gr Vice (Employee Name) PD # POINT OF CONTACT INFORMATION Supervisor’s Name Phone Email POC/AO Phone Email SME Phone Email
Position Data
Target PP, Ser, Grade PD Attached to RPA (Yes or N/A) Is PD Accurate? (Yes or No) NTE Date (i.e. 120 days, 1 year, 366 days, etc.) Physical Exam Required (Yes or No) Drug testing Required (Yes or No) Certification or Licensing Required? (Yes or No) If yes, what type?
Other Recruitment Information
Recruit at Grade Level(s): Number of Vacancies PCS Authorized (Yes or No) Recruitment Incentives (Yes or No) Duration of Announcement (Minimum 5 days)
IDENTIFY THOSE RECRUITMENT SOURCES YOU WOULD LIKE TO UTILIZE TO FILL YOUR VACANCY.
Area of Consideration
DE –U.S. Citizen USUHS Only (Current Career/Career-Conditional Employees) VRA and Veterans with 30% or more Disability Re-employed Annuitants Current Federal (Includes VEOA Eligible) Individuals with Disabilities (Schedule A) Current Department of Defense (DOD) Student Educational Employment Program Reinstatement Eligible Wounded Warriors Military Spouses (E.O. 13473, E.O. 12721) VEOA
IDENTIFY 3-5 MAJOR DUTIES AND THE CORRESPONDING COMPETENCIES (Knowledge, skills and abilities) WHICH SUPPORT THESE DUTIES.
All duties and competencies must be supported in the position description.
1.
2.
3.
4.
5.
UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES
Civilian Human Resources Office 4301 JONES BRIDGE ROAD
BETHESDA, MARYLAND 20814-4799
Date
MEMORANDUM FOR HUMAN RESOURCES ACTIONS COMMITTEE THROUGH:
SUBJECT: Justification - Establish and Recruit/Fill for ____________________ The justification memorandum shall address the following: 1. Reason/Rationale
2. Requirement/Need
3. Impact on mission
4. Fund Explanation
VOLUNTEER AGREEMENT FOR
PRIVACY ACT STATEMENT
AUTHORITY: Section 1588 of Title 10, U.S. Code, and E.O. 9397.
PRINCIPAL PURPOSE(S): To document voluntary services provided by an individual, including the hours of service performed, and to obtain agreement from the volunteer on the conditions for accepting the performance of voluntary service.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however failure to complete the form may result in an inability to accept voluntary services or an inability to document the type of voluntary services and hours performed.
PART I - GENERAL INFORMATION
5. WHERE SERVICE OCCURS4.
7. OF WEEK6. OCCURS
9. OF VOLUNTEER SERVICES
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved volunteer services, tort claims, the Privacy Act, criminal conflicts of interest, and defense of certain suits arising out of legal malpractice. I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. service providers and agree to participate in any training required by the installation or unit in order for me to perform the voluntary services that I am offering. follow all rules and procedures of the installation or unit that apply to the voluntary services I will be providing.
1. VOLUNTEER (Last, First, Middle Initial)
a. SIGNATURE OF VOLUNTEER b. SIGNED (YYYYMMDD)
2. 3. BIRTH (YYYYMMDD)
11.a. TYPED NAME OF ACCEPTING OFFICIAL (Last, First, Middle Initial)
b. c. DATE SIGNED (YYYYMMDD)
PART IV - TO BE COMPLETED AT END OF VOLUNTEER'S SERVICE BY VOLUNTEER SUPERVISOR 14. AMOUNT OF VOLUNTEER TIME DONATED a. YEARS (2,087
hours=1 year) b. c. DAYS d.
15. SIGNATURE 16. TERMINATION DATE (YYYYMMDD)
17.a. TYPED NAME OF SUPERVISOR (Last, First, Middle Initial)
b. c. DATE SIGNED (YYYYMMDD)
APPROPRIATED FUND ACTIVITIES NONAPPROPRIATED FUND INSTRUMENTALITIES
8.
10. CERTIFICATION
PART III - VOLUNTEER IN NONAPPROPRIATED FUND INSTRUMENTALITIES
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved volunteer services and liability for tort claims as specified in 10 U.S.C. Section 1588(d)(2). I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be bound by the laws and regulations applicable to voluntary service providers, and agree to participate in any training required by the installation or unit in order for me to perform the voluntary services that I am offering. cedures of the installation or unit that apply to the voluntary services
13.a. TYPED NAME OF ACCEPTING OFFICIAL (Last, First, Middle Initial)
a. SIGNATURE OF VOLUNTEER b. SIGNED (YYYYMMDD)
12. CERTIFICATION
b. c. DATE SIGNED (YYYYMMDD)
PART II - VOLUNTEER IN APPROPRIATED FUND ACTIVITIES
ORGANIZATION/UNIT INSTALLATION
ANTICIPATED DAYS PROGRAM WHERE SERVICE
DESCRIPTION
I agree to be bound by the laws and regulations applicable to voluntary I agree to
TYPED NAME OF
DATE
SSN DATE OF
SIGNATURE
WEEKS HOURS
SIGNATURE
ANTICIPATED HOURS
I agree to follow all rules and prothat I am offering.
DATE
SIGNATURE
DD FORM 2793, FEB 2002 PREVIOUS EDITION IS OBSOLETE. Exception to Standard Form 50 granted by Office of Personnel Management (OPM) waiver.
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Sample Position Description -Professor (CHAIRPERSON)
PROFESSOR (CHAIRPERSON) AD-602-00
INTRODUCTION The mission of the Uniformed Services University of the Health Sciences (USU) is to provide the highest quality education and research programs in the health sciences to those selected individuals who demonstrate dedication to a career in the health professions of the uniformed services. The USU is authorized to grant appropriate advanced academic degrees and to establish postdoctoral, postgraduate, and technological institutes related to treatment and research in the health sciences. USU develops and supports academic and training programs designed to ensure maximum utilization of the health science labor force, facilities, and equipment within the Department of Defense and military medical departments worldwide. This position is located in the USU, F. Edward Hébert School of Medicine (SOM), Department of __________. The Department of __________ is responsible for __________. The incumbent of this position serves as the Chairperson of the Department and is responsible for management, oversight, administration, and evaluations of faculty, staff, and students to ensure that department program objectives, goals, and requirements are met. MAJOR DUTIES AND RESPONSIBILITIES Incumbent serves as the Chief Executive of the Department of __________, a clinical medicine department, and as such is responsible for setting the tactical and strategic course for the department. The principle of shared governance is essential in the academic setting and departmental faculty will be actively engaged in significant decisions concerning the department. In coordination with other faculty members from within and outside the Department of __________, and with the approval of the Dean, (SOM) plans and develops the curriculum for the Department of __________. The incumbent is responsible for providing a productive and meaningful learning environment for the students by continually evaluating and revising the curriculum as needed. Coordinates with the Dean and the Chairpersons of other clinical and basic science departments of the University to determine the variety and scope of instructional techniques to be used such as lectures, discussions, laboratory exercises, seminars, conferences, audiovisual media, and computer-assisted problems appropriate to accomplish the learning objectives. Responsible for preparing and evaluating training manuals and other educational materials for the students. Develops and organizes specific courses of study for the Department of __________ which provide practical experiences in learning fundamentals of sound history and physical examination and diagnosis, and understanding and interrelationships between patient and disease, evaluating patients with medical or surgical disorders. Responsible for all patient care activities within the Department and reports to the Commanding Officer of the teaching hospitals regarding the quality of patient care on medical services of the teaching hospitals. The incumbent also performs patient care activities. Organizes and monitors continuing education programs for the Department. Participates in faculty committees, prepares staff reports and makes recommendations on policies for the University as a whole. Responsible for obtaining highly qualified specialists as visiting lecturers and panelists. Responsible to encourage, develop, and support research activities within the department. Oversees and evaluates all research and teaching activities for the Department and supervises and directs the entire Department. Participates in investigational research and development projects, directs experimental activities,
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Sample Position Description -Professor (CHAIRPERSON)
evaluates data, draws conclusions and publishes results. Reviews and critiques research development areas; develops, monitors, and evaluates contractual research and development arrangements. Serves as research advisor to graduate students in the field of __________ including all of its specializations in planning programs, setting objectives, organizing protocols, evaluating progress, etc. Ensures compliance with regulations and procedures by reviewing literature and preparation of protocols by subordinates.
Plans and directs the organization and operation of the departmental laboratories and oversees the design, development, validation, and implementation of all relevant laboratory experiments, and computer-based research projects or studies. Oversees the selection of laboratory and related equipment, the ordering of all supplies and materials for the Department, and is responsible for ensuring the maintenance of all teaching and research equipment. Writes and edits for publication texts, articles, monographs and other materials on the subject of __________ and related areas for use in the course of study and for research purposes. Determines and provides justification for the operational and research budget requirements for the Department. Responsible for ascertaining the availability of logistics support and for the preparation of budget reports and other management documentation. Assures all aspects of the USU internal control program are operable within the Department in order to protect and conserve government resources. Performs periodic program reviews and evaluations for effective utilization of facilities, space, budgeting, equipment and personnel. Formulates research needs of the Department and evaluates the significance of new directions and merging trends within the research field to achieve a quality and quantity of research that meets the Department’s missions and objectives. Evaluates the seriousness of problems and difficulties in achieving Department program objectives and in advancing research efforts. Initiates appropriate action to insure that proper emphasis is given to critical and far-reaching research. Prepares and encourage physicians and scientists to develop articles and reports, and disseminates vital data to other investigators and physicians for whom the data is of significant value. Establishes criteria and standards for others to follow in planning, reviewing, and evaluating Department programs. Exercises personnel management responsibilities and is responsible for complying with equal employment opportunity polices and Government and agency internal control requirements. Structure positions for maximum efficiency, economy, and productivity to achieve the organization’s mission. Performs the full range of supervisory and managerial authorities related to the recruitment and selection of subordinates, assignment of work, coordination of programs, management advisory services, technical work direction, establishing performance goals or objectives and evaluation of subordinates, resolving complaints, approving or proposing disciplinary actions, determining or approving career development and training needs, approving expenditures of funds, recommending or approving awards and bonuses, determining means to improve productivity, and other delegated authorities. Demonstrates fairness and equity in making managerial decisions concerning selections, pay, work assignments, training, and award recognition. Represents the University at professional gatherings, delivers lectures and participates in meetings and panel discussions at other institutions. Maintains professional contacts with other medical schools throughout the country and maintains advantageous working relationships with members of professional organizations and other universities to keep aware of new developments. Remains knowledgeable of newer developments in the field of responsibility through reading professional journals and reviews, familiarization with new instrumentation and techniques, attendance at professional
-3-
Sample Position Description -Professor (CHAIRPERSON)
meetings, participation in scholarly symposia, and informal and continuing interaction with other federal and civilian organizations. Performs other duties as assigned. SUPERVISORY CONTROLS The incumbent of this position works under the direction of the Dean, SOM, who evaluates the incumbent's performance. QUALIFICATION REQUIREMENTS The incumbent must bring to this position a minimum of an earned M.D., or D.O., degree, plus certification by the American Board of __________ and state medical licensure. The successful candidate will also possess substantial experience in medical and graduate education, educational leadership, research, and administration. The successful candidate will demonstrate comprehensive knowledge of executive management in academic organizations. Knowledge of military medical organizations and experience with military medical educational programs, health care delivery systems, and accreditation standards are also required. Exceptional interpersonal skills, as well as outstanding written and oral communication skills, are essential. Academic accomplishment, as reflected by a significant number of scientific publications in appropriate critically reviewed journals, is required. The successful candidate must be academically qualified for a faculty appointment at the Professor level in accordance with USUHS academic policies. OTHER POSITION FACTORS Assignment as Chairperson is an administrative assignment and is without tenure. This assignment is for a five-year term and may be renewed with no limit on the number of renewals. Assignment as Chairperson is not a continuous appointment and as such the incumbent serves at the pleasure of his or her immediate supervisor(s) and may be relieved as Chair at any time. The incumbent of this position will be subject to random drug testing under the USU Drug-Free Workplace Program. This position does not require a secret clearance.
Sample Position Description –Full Professor
PROFESSOR AD-0401-00
INTRODUCTION The mission of the Uniformed Services University of the Health Sciences (USU) is to provide the highest quality education and research programs in the health sciences to those selected individuals who demonstrate dedication to a career in the health professions of the uniformed services. The USU is authorized to grant appropriate advanced academic degrees and to establish postdoctoral, postgraduate, and technological institutes related to treatment and research in the health sciences. USU develops and supports academic and training programs designed to ensure maximum utilization of the health science labor force, facilities, and equipment within the Department of Defense and military medical departments worldwide.
This position is located in the USU, F. Edward Hébert School of Medicine (SOM), Department of __________. The Department of __________ is responsible for providing __________. The incumbent will serve as a Professor in the Department of __________ responsible for teaching, research, scholarly activities, and administrative assignments.
MAJOR DUTIES Serves as a Professor in the Department of __________, and as such, is responsible for teaching, research, scholarly activities, and administrative assignments. In coordination with other faculty members of the department, assists in planning and development of curriculum for the department. Supervises groups of medical students, interns, residents and postdoctoral and graduate assistants at the tutorial level in the laboratory. Responsible for teaching new research techniques, use of appropriate instruments and equipment, and statistical and analytical procedures. Prepares materials for presentation, provides daily supervision and reviews student performance. Serves as advisor to pre-doctoral and post-doctoral assistants in guiding their training programs. Prepares and presents lectures in area of __________ and __________ to the entire student body.
Serves as Director of Clinical Training within his/her area of responsibility; performing such duties as; advising students, supervising curriculum, coordinating practicums and clerkships, maintaining coordination with adjunct and clinical faculty, and complying with accreditation requirements.
Actively participates in daily research work at bench level and is responsible for data review and analysis from individuals within his/her area of responsibility.
Participates in investigational research and developmental projects, directs experimental activities, evaluates data, draws conclusions, and publishes results. Reviews and critiques research and developmental areas, and develops, monitors, and evaluates contractual research and development arrangements. Serve as research advisor to graduate students in field of expertise, assists in planning programs, setting objectives, evaluating progress, etc. Responsible for ascertaining the availability of logistics support. Writes and edits publications, curriculum, exams, articles, monograms, and other materials for use in the source of study and for research purposes.
Serves on major standing committees, and may be required to prepare staff reports. Represents the University at professional gatherings, delivers lectures, and participates in meetings and panel discussions at other
Sample Position Description –Full Professor
institutions. Maintains professional contacts with other medical schools and professional organizations throughout the country to locate and exchange information of mutual interest. Performs other duties as assigned. SUPERVISORY CONTROLS The incumbent work under the general direction of the Chairperson, Department of __________ who evaluates performance. QUALIFICATION REQUIREMENTS Incumbent must bring to this position a minimum of an earned Ph.D., in __________ sciences or closely related field, plus substantial experience in medical school teaching, educational administration, and research and development. The incumbent must also possess experience and expertise as reflected by a significant number of scientific publications in critically reviewed scientific journals as appropriate to his/her research, and active membership in scholarly societies appropriate to the Department of __________ and the area of expertise. Experience with medical applications of electronic data processing is desirable. The successful candidate must be academically qualified for a faculty appointment at the Professor level in accordance with USUHS academic policies. OTHER POSITION FACTORS This position is in the tenure eligible track. The position does not require a secret clearance.
Sample Position Description –Associate Professor
ASSOCIATE PROFESSOR AD-0401-00
INTRODUCTION The mission of the Uniformed Services University of the Health Sciences (USU) is to provide the highest quality education and research programs in the health sciences to those selected individuals who demonstrate dedication to a career in the health professions of the uniformed services. The USU is authorized to grant appropriate advanced academic degrees and to establish postdoctoral, postgraduate, and technological institutes related to treatment and research in the health sciences. USU develops and supports academic and training programs designed to ensure maximum utilization of the health science labor force, facilities, and equipment within the Department of Defense and military medical departments worldwide.
This position is located in the USU, F. Edward Hébert School of Medicine (SOM), Department of __________. The Department of __________ is responsible for providing __________. The incumbent will serve as an Associate Professor in the Department of __________ responsible for teaching, research, scholarly activities, and administrative assignments.
MAJOR DUTIES Serves as an Associate Professor in the Department of __________, and as such, is responsible for teaching, research, scholarly activities, and administrative assignments. In coordination with other faculty members of the department, assists in planning and development of curriculum for the department. Supervises groups of medical students, interns, residents and postdoctoral and graduate assistants at the tutorial level in the laboratory. Responsible for teaching new research techniques, use of appropriate instruments and equipment, and statistical and analytical procedures. Prepares materials for presentation, provides daily supervision and reviews student performance. Serves as advisor to pre-doctoral and post-doctoral assistants in guiding their training programs. Prepares and presents lectures in area of __________ and __________ to the entire student body.
Serves as Director of Clinical Training within his/her area of responsibility; performing such duties as; advising students, supervising curriculum, coordinating practicums and clerkships, maintaining coordination with adjunct and clinical faculty, and complying with accreditation requirements.
Actively participates in daily research work at bench level and is responsible for data review and analysis from individuals within his/her area of responsibility.
Participates in investigational research and developmental projects, directs experimental activities, evaluates data, draws conclusions, and publishes results. Reviews and critiques research and developmental areas, and develops, monitors, and evaluates contractual research and development arrangements. Serve as research advisor to graduate students in field of expertise, assists in planning programs, setting objectives, evaluating progress, etc. Responsible for ascertaining the availability of logistics support. Writes and edits publications, curriculum, exams, articles, monograms, and other materials for use in the source of study and for research purposes.
Serves on major standing committees, and may be required to prepare staff reports. Represents the University at professional gatherings, delivers lectures, and participates in meetings and panel discussions at other
Sample Position Description –Associate Professor
institutions. Maintains professional contacts with other medical schools and professional organizations throughout the country to locate and exchange information of mutual interest. Performs other duties as assigned. SUPERVISORY CONTROLS The incumbent work under the general direction of the Chairperson, Department of __________ who evaluates performance. QUALIFICATION REQUIREMENTS Incumbent must bring to this position a minimum of an earned Ph.D., in __________ sciences or closely related field, plus substantial experience in medical school teaching, educational administration, and research and development. The incumbent must also possess experience and expertise as reflected by a significant number of scientific publications in critically reviewed scientific journals as appropriate to his/her research, and active membership in scholarly societies appropriate to the Department of __________ and the area of expertise. Experience with medical applications of electronic data processing is desirable. The successful candidate must be academically qualified for a faculty appointment at the Associate Professor level in accordance with USUHS academic policies. OTHER POSITION FACTORS This position is in the tenure eligible track. The position does not require a secret clearance.
Sample Position Description –Assistant Professor
ASSISTANT PROFESSOR AD-0401-00
INTRODUCTION The mission of the Uniformed Services University of the Health Sciences (USU) is to provide the highest quality education and research programs in the health sciences to those selected individuals who demonstrate dedication to a career in the health professions of the uniformed services. The USU is authorized to grant appropriate advanced academic degrees and to establish postdoctoral, postgraduate, and technological institutes related to treatment and research in the health sciences. USU develops and supports academic and training programs designed to ensure maximum utilization of the health science labor force, facilities, and equipment within the Department of Defense and military medical departments worldwide.
This position is located in the USU, F. Edward Hébert School of Medicine (SOM), Department of __________. The Department of __________ is responsible for providing __________. The incumbent will serve as an Assistant Professor in the Department of __________ responsible for teaching, research, scholarly activities, and administrative assignments.
MAJOR DUTIES Serves as an Assistant Professor in the Department of __________, and as such, is responsible for teaching, research, scholarly activities, and administrative assignments. In coordination with other faculty members of the department, assists in planning and development of curriculum for the department. Supervises groups of medical students, interns, residents and postdoctoral and graduate assistants at the tutorial level in the laboratory. Responsible for teaching new research techniques, use of appropriate instruments and equipment, and statistical and analytical procedures. Prepares materials for presentation, provides daily supervision and reviews student performance. Serves as advisor to pre-doctoral and post-doctoral assistants in guiding their training programs. Prepares and presents lectures in area of __________ and __________ to the entire student body.
Serves as Director of Clinical Training within his/her area of responsibility; performing such duties as; advising students, supervising curriculum, coordinating practicums and clerkships, maintaining coordination with adjunct and clinical faculty, and complying with accreditation requirements.
Actively participates in daily research work at bench level and is responsible for data review and analysis from individuals within his/her area of responsibility.
Participates in investigational research and developmental projects, directs experimental activities, evaluates data, draws conclusions, and publishes results. Reviews and critiques research and developmental areas, and develops, monitors, and evaluates contractual research and development arrangements. Serve as research advisor to graduate students in field of expertise, assists in planning programs, setting objectives, evaluating progress, etc. Responsible for ascertaining the availability of logistics support. Writes and edits publications, curriculum, exams, articles, monograms, and other materials for use in the source of study and for research purposes.
Serves on major standing committees, and may be required to prepare staff reports. Represents the University at professional gatherings, delivers lectures, and participates in meetings and panel discussions at other
Sample Position Description –Assistant Professor
institutions. Maintains professional contacts with other medical schools and professional organizations throughout the country to locate and exchange information of mutual interest. Performs other duties as assigned. SUPERVISORY CONTROLS The incumbent work under the general direction of the Chairperson, Department of __________ who evaluates performance. QUALIFICATION REQUIREMENTS Incumbent must bring to this position a minimum of an earned Ph.D., in __________ sciences or closely related field, plus substantial experience in medical school teaching, educational administration, and research and development. The incumbent must also possess experience and expertise as reflected by a significant number of scientific publications in critically reviewed scientific journals as appropriate to his/her research, and active membership in scholarly societies appropriate to the Department of __________ and the area of expertise. Experience with medical applications of electronic data processing is desirable. The successful candidate must be academically qualified for a faculty appointment at the Assistant Professor level in accordance with USUHS academic policies. OTHER POSITION FACTORS This position is in the tenure eligible track. The position does not require a secret clearance.
Sample Position Description – Research Associate
RESEARCH ASSOCIATE AD-0401-00
INTRODUCTION The mission of the Uniformed Services University of the Health Sciences (USU) is to provide the highest quality education and research programs in the health sciences to those selected individuals who demonstrate dedication to a career in the health professions of the uniformed services. The USU is authorized to grant appropriate advanced academic degrees and to establish postdoctoral, postgraduate, and technological institutes related to treatment and research in the health sciences. USU develops and supports academic and training programs designed to ensure maximum utilization of the health science labor force, facilities, and equipment within the Department of Defense and military medical departments worldwide. This position is located in the USU, F. Edward Hébert School of Medicine, Department of __________. The Department of __________ is responsible for providing __________. The incumbent serves as a Research Associate in the Department of __________, responsible for conducting research projects and activities in support of department faculty members. MAJOR DUTIES Serves as a Research Associate in the Department of __________, and as such, is responsible for conducting research projects and activities in support of department faculty members. The incumbent will be directly involved in the execution and design of environmental health science research. Assists in developing, implementing, and managing research projects to study and address issues relating to the health impacts of the built environment and sprawl, climate change, sustainability, and/or human health risks related to alternative energy sources. Conducts quantitative (e.g. GIS methodologies, spatiotemporal mapping) and qualitative research related to the implications of the built environment, including land use, commuting patterns, and housing, for physical activity, diet, obesity, and other aspects of health. Conducts research examining the intersection of social and environmental determinants of population health and health disparities. Serves as a member of a research team and collaborates with the investigator in carrying out environmental health science research protocols. Assists in designing, developing, executing, and implementing scientific research, including managing study logistics; data collection, entry, management and analyses; literature reviews; extensive assistance with the submission of review board approvals and grant applications; and assistance with the preparation of presentations at scientific meetings and publications in journals. Performs other duties as assigned.
SUPERVISORY CONTROLS The incumbent works under the supervision of the Assistant Professor of the assigned research project, who evaluates performance; and the general direction of the Chairperson, Department of __________. QUALIFICATION REQUIREMENTS Incumbent must possess a master’s degree in environmental health sciences, environmental epidemiology, health geography, geographic information systems (GIS), spatial epidemiology, or related field. This level of expertise and knowledge may also be evidenced by possession of a Bachelor’s degree in the area of science required by the position, combined with a minimum of two years of specialized experience in the scientific specialization required by the position. Expertise in exposure science, spatial statistics, demography,
Sample Position Description – Research Associate
environmental health risk assessment, community-based participatory research, or related fields are desired. Successful candidate must have excellent oral and written communication skills, as well as, analytical skills and strong problem-solving capabilities. Experience with quantitative data analysis and programming skills with STATA and ArcGIS is strongly desired. OTHER POSITION FACTORS This position is in the tenure ineligible track. The position does not require a secret clearance.
Sample Position Description –Postdoctoral Fellow
POSTDOCTORAL FELLOW AD-0401-00
INTRODUCTION The mission of the Uniformed Services University of the Health Sciences (USU) is to provide the highest quality education and research programs in the health sciences to those selected individuals who demonstrate dedication to a career in the health professions of the uniformed services. The USU is authorized to grant appropriate advanced academic degrees and to establish postdoctoral, postgraduate, and technological institutes related to treatment and research in the health sciences. USU develops and supports academic and training programs designed to ensure maximum utilization of the health science labor force, facilities, and equipment within the Department of Defense and military medical departments worldwide. This position is located in the USU, F. Edward Hébert School of Medicine, Department of __________. The Department of __________ is responsible for providing __________. The incumbent serves as a Postdoctoral Fellow in the Department of __________, responsible for the development, modification and performance of techniques relating to specialized research projects. MAJOR DUTIES Serves as a Postdoctoral Fellow in the Department of __________, and as such, is responsible for conducting research projects using in vitro and in vivo models neuron/bone communication. In support of department faculty members, he/she will perform experiments and participate in laboratory organization, personnel training, and experimental design. The incumbent will participate in the initiation of projects studying sensory neuron innervation to bone, and will be expected to design and perform experiments involving primary neuronal culture and molecular biology. Additional responsibilities include; surgery on rats and mice, preparation of RNA and protein from animal tissue and cells, quantitative PCR, western blotting, cell cultures, immunohistochemistry and microscopy. The incumbent serves as a member of a research team and collaborates with the investigator in conducting experiments and achieving project goals. Assist in the instruction of medical and graduate students, postdoctoral fellows, residents, visiting scientists, guest researches, and other laboratory personnel in laboratory procedures and techniques. Conducts routine laboratory experiments with limited supervision, while observing good laboratory practice, working with biohazardous chemicals and rodent handling. Follows appropriate regulations and takes necessary precautions in handling such materials. Responsible for designing, developing, executing, and implementing scientific research, including managing study logistics; data collection, entry, management and analyses; literature reviews; and provides extensive assistance with the submission of review board approvals and grant applications. Conducts literature searches, assemble pertinent scientific information bearing on research programs and assist in planning research approaches. Maintains detailed and organized records of experimental procedures and observations. Utilizes computer hardware and software for accumulation and analysis of data, word processing, preparing final reports and in preparation of graphic materials for presentation at scientific meetings, or publication in scientific journals. Performs other duties as assigned.
SUPERVISORY CONTROLS
Sample Position Description –Postdoctoral Fellow
The incumbent works under the supervision of the Assistant Professor of the assigned research project, who evaluates performance; and the general direction of the Chairperson, Department of __________. QUALIFICATION REQUIREMENTS Incumbent must bring to this position a minimum of a doctoral degree in Neuroscience, Pharmacology or a closely related discipline. The incumbent must possess two years of postdoctoral training or equivalent research skill, subject knowledge, and expertise and experience as reflected by publications in peer-reviewed scientific journals, as appropriate to his/her research. Experience with and knowledge of neurobiology, basic molecular biology and cell culture techniques, as well as the handling of, and performing surgeries on rodents. Successful candidate must have excellent oral and written communication skills, as well as, analytical skills and strong problem-solving capabilities. A strong background in molecular neurobiology research is desired. OTHER POSITION FACTORS This position is in the tenure ineligible track. The position does not require a secret clearance.
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 1 of 8
Instructions
There are five parts in this form: Part A - To be completed by applicant or employee. Signature of the applicant or employee certifies that the information
provided is complete and accurate; and that the applicant or employee consents to the release of the examination results to the employing agency.
Part B - To be completed by the appointing officer before the medical examination: identifies the purpose of the
examination; the position title, series and grade; generally describes the position; and shows the specific functional requirements and environmental factors that the work requires.
Part C - To be completed and signed by the examining physician, and returned to the employing agency in the pre-paid/
pre-addressed “Confidential-Medical” envelope provided. Part D - To be completed by the agency medical officer who reviews the examination results and recommends action. Part E - To be completed by the agency human resources officer in order to document the personnel action that is
rendered.
Privacy Act StatementSolicitation of this information is authorized by Section 552a of Title 5, United States Code, regarding records maintained on individuals; Section 3301 of Title 5, United States Code, regarding determination as to an individual's fitness for employment with regard to age, health, character, knowledge and ability; and Section 3312 of Title 5 United States Code, regarding waiver of physical qualifications for preference eligibles. This form is used to collect medical information about individuals who are incumbents of positions in the Federal Government which require physical fitness testing and medical examinations, or individuals who have been selected for such a position contingent upon successful completion of physical fitness testing and medical examinations as a condition of their employment. The primary use of this information will be to determine the nature of a medical or physical condition that may affect safe and efficient performance of the work described. Additional potential routine uses of this information include using it to ensure fair and consistent treatment of employees and job applicants, to adjudicate requests to pass over preference eligibles, or to adjudicate claims of discrimination under the Rehabilitation Act of 1973, as amended. Completion of this form is voluntary; however, failure to complete the form may result in no further consideration of an applicant, or a determination that an employee is no longer qualified for his or her position. In addition, incomplete, misleading, or untruthful information provided on the form may result in delays in processing the form for employment, termination of employment, or criminal sanction.
Public Burden Statement We estimate an average of two to three hours per response to complete, including the time for reviewing instructions, getting needed information, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management (OPM), Strategic Human Resources Policy, Medical Policy and Programs Division, Attn: OMB Number (3206-0250), 1900 E Street, NW, Washington, D.C. 20415. The OMB number, 3206-0250, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 2 of 8
Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE1. Name (Last, First, Middle Initial)
2. Federal Employee Number 3. Sex 4. Birth Date (month, day, year)MaleFemale
5. Do you have any medical disorder or physical impairment which would interfere in any way with the full performance of the duties shown in Part B, No. 3?
Yes No
(If your answer is YES, explain fully to the physician performing the examination)
6. Address (including City, State, Zip Code)
7. E-mail Address 8. Telephone Numbers (with Area Code)
9. Applicant or Employee Consent and Certification
I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting information that is incomplete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for employment. Furthermore, consistent with the Privacy Act Statement, I authorize the release to my employing agency of all information contained on this examination form and all other forms generated as a direct result of my examination.
10. Signature (Do not print) 11. Date (month, day, year)
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 3 of 8
Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER1. Purpose of examination 2. Position Title, Series, and Grade
Pre-placementOther (Specify)_____________________________
3. Brief description of what the position requires the employee to do.
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 4 of 8
Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this
position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or fire fighting, attach the specific medical standards for the information of the examining physician.
4a. Functional Requirements
Heavy lifting, 45 pounds and over
Moderate lifting, 15-44 pounds
Light lifting, under 15 pounds
Heavy carrying, 45 pounds and over
Moderate carrying, 15-44 pounds
Light carrying, under 15 pounds
Straight pulling (_____ hours)
Pulling hand over hand (_____ hours)
Pushing (_____ hours)
Reaching above shoulder
Use of fingers
Both hands required
Walking (______ hours)
Standing (______ hours)
Crawling (______ hours)
Kneeling (______ hours)
Repeated bending (______ hours)
Climbing, legs only (______ hours)
Climbing, use of legs and arms
Both legs required
Operation of crane, truck, tractor, or motor vehicle
Ability for rapid mental and muscular coordination simultaneously
Ability to use and desirability of using firearms
Near vision correctable at 13” to 16” to Jaeger 1 to 4
Far vision correctable in one eye to 20/20 and to 20/40 in the other
Specific visual requirement (specify) ______________________________
Both eyes required
Depth perception
Ability to distinguish basic colors
Ability to distinguish shades of colors
Hearing (aid permitted)
Hearing without aid
Specific hearing requirements (specify)
Other (specify)
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
4b. Environmental Factors
Outside
Outside and inside
Excessive heat
Excessive cold
Excessive humidity
Excessive dampness or chilling
Dry atmospheric conditions
Excessive noise, intermittent
Constant noise
Dust
Silica, asbestos, etc.
Fumes, smoke, or gases
Solvents (degreasing agents)
Grease and oils
Radiant energy
Electrical energy
Slippery or uneven walking surfaces
Working around machinery with moving parts
Working around moving objects or vehicles
Working on ladders or scaffolding
Working below ground
Unusual fatigue factors (specify)
______________________________
Working with hands in water
Explosives
Vibration
Working closely with others
Working alone
Protracted or irregular hours of work
Other (specify)
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 5 of 8
Part C. TO BE COMPLETED BY EXAMINING PHYSICIANNOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and environmental factors checked in Part 4 of this form. Please take these, and the brief description of the job duties, into consideration as you make your examination and report your findings and conclusions.
1. Height ________ Feet, ________ Inches. Weight: ________ Pounds.
2. Eyes: 20 20 20 20
a. Distant vision (Snellen): without corrective lenses: right ____ left ____ ; with corrective lenses, if worn; right ____ left ____
b. Depth perception Type of test: _____________________________
___________ Seconds of Arc
Number correct: _____ of _____ tested
Interpretation
c. Peripheral vision Right Nasal ______ degrees Temporal ______ degrees
Left Nasal ______ degrees Temporal ______ degrees
d. What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant?
Test each eye separately.
without corrective lenses: with corrective lenses, if used: L ______in. to _____ in. L _____ in. to _____ in. R______ in. to _____ in. R _____ in. to_____ in.
e. Color vision: Is color vision normal by Ishihara or other color plate test? If not, can applicant pass lantern test? Can see red/green/yellow?
Normal Abnormal
Jaeger No. 2 Type The President may - (1) prescribe such regulations for the admission of individuals into the civil service in the executive branch as will best promote the efficiency of that service; (2) ascertain the fitness of applicants as to age, health, character, knowledge, and ability for the employment sought; and (3) appoint and prescribe the duties of individuals to make inquiries for the purpose of this section. (Title 5 U.S. Code 3301)
Yes No
Yes No
Yes No
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 6 of 8
Part C. CONTINUED - TO BE COMPLETED BY EXAMINING PHYSICIAN
3. Ears: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.) Ordinary conversation: Right Ear _____ ; 20 ft. Left Ear _____ 20 ft.
Audiometer in dB (if given) for Right Ear:
250 500 1000 2000 3000 4000 5000 6000 7000 8000
Audiometer in dB (if given) for Left Ear:
250 500 1000 2000 3000 4000 5000 6000 7000 8000
4. Other Findings: Describe any abnormality (including diseases, scars, and disfigurations). Include brief pertinent history. If normal, so indicate.
a. Eyes, ears, nose, and throat (including tooth and oral hygiene) b. Abdomen c. Head and back (including face, hair, and scalp)
d. Peripheral blood vessels
e. Speech (note any malfunction)
f. Extremities (including strength, range of motion)
g. Skin and lymph nodes (including thyroid gland)
h. Urinalysis (if indicated)
SP. Gr. __________ Sugar __________ Blood __________
Albumen __________ Casts __________ Pus __________
i. Respiratory tract (X-ray if indicated) j. Heart (size, rate, rhythm, function)
Blood pressure ______________
Pulse _______________
EKG (if indicated)
k. Back (special consideration for positions involving heavy lifting and other strenuous duties)
l. Neurological (including reflexes, sensation) and mental health
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 7 of 8
Part C. CONTINUED - TO BE COMPLETED BY EXAMINING PHYSICIAN5. Conclusions: Summarize below any medical findings that in your opinion, would limit this person's ability to perform these job duties or
make them a hazard to themselves or others. If none, so indicate.
No limiting conditions for this job
Limiting conditions as follows:
6. Examining Physician's Name 7. E-Mail Address
8. Address (Including Street, City, State and ZIP Code) 9. Telephone Number
10. Signature of Examining Physician 11. Date (Month, Day, Year)
IMPORTANT: After signing, return the entire form intact in the pre-addressed “Confidential-Medical” envelope which the person you examined gave you.
CERTIFICATE OF MEDICAL EXAMINATION U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved OMB No. 3206 - 0250
To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.
U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only
Optional Form 178 July 2009
Formerly SF 78 Previous editions not useablePage 8 of 8
FOR AGENCY USE ONLYPart D. TO BE COMPLETED BY AGENCY MEDICAL OFFICER (if one is available)
NOTE: Review the attached certificate of medical examination and make your recommendations in item 1 below. 1. Recommendation:
Hire or retain; describe limitations, if any, here.
Take action to separate or do not hire; explain why.
2. Agency Medical Officer's Name 3. E-Mail Address
4. Address (Including Street, City, State and ZIP Code) 5. Telephone Number
6. Signature of Agency Medical Officer 7. Date (Month, Day, Year)
FOR AGENCY USE ONLY
Part E. TO BE COMPLETED BY AGENCY HUMAN RESOURCES OFFICER 1. Action Taken:
Hired or Retained
Non-Selected for Appointment, or Eligibility Objected To
Action Taken to Separate
2. Agency Human Resources Officer's Name 3. E-Mail Address
4. Address (Including Street, City, State and ZIP Code) 5. Telephone Number
6. Signature of Agency Human Resources Officer 7. Date (Month, Day, Year)
POSITION DESCRIPTION (Please Read Instructions on the Back) 1. Agency Position No.
2. Reason for Submission
Redescription
Reestablishment
3. Service
Hdqtrs
5. Duty Station 6. OPM Certification No.
Explanation (Show any positions replaced)
7. Fair Labor Standards ActExempt
8. Financial Statements RequiredExecutive Personnel Financial Disclosure
9. Subject to IA Action
Yes 10. Position Status
Competitive
Excepted (Specify in Remarks)
SES (Gen.) SES (CR)
11. Position IsSupervisory
Managerial
Neither
12. Sensitivity
Employment and Financial Interest
1--Non- Sensitive
2--Noncritical Sensitive
3--Critical
4--Special Sensitive
13. Competitive Level Code
14. Agency Use
15. Classified/Graded by Official Title of Position Pay Plan Occupational Code Grade Initials Datea. Office of Personnel
Management
b. Department, Agency or Establishment
c. Second Level Review
d. First Level Review
e. Recommended by Supervisor or Initiating Office
16. Organizational Title of Position (if different from official title) 17. Name of Employee (if vacant, specify)
18. Department, Agency, or Establishment c. Third Subdivision
a. First Subdivision
b. Second Subdivision
d. Fourth Subdivision
e. Fifth Subdivision
19. Employee Review-This is an accurate description of the major duties and responsibilities of my position.
Signature of Employee (optional)
Supervisory Certification. I certify that this is an accurate statement of the major duties and responsibilities of this position and its organizational relationships, and that the position is necessary to carry out Government functions for which I am responsible. This certification is made with the knowledge that
20. this information is to be used for statutory purposes relating to appointment and payment of public funds, and that false or misleading statements may constitute violations of such statutes or their implementing regulations.
b. Typed Name and Title of Higher-Level Supervisor or Manager (optional)
Signature Date Signature
21. Classification/Job Grading Certification. I certify that this posi- tion has been classified/graded as required by Title 5, U.S. Code, in conformance with standards published by the U.S. Office of Personnel Management or, if no published standards apply direct- ly, consistently with the most applicable published standards.
a. Typed Name and Title of Immediate Supervisor
Typed Name and Title of Official Taking Action
Signature
22. Position Classification Standards Used in Classifying/Grading Position
Information for Employees. The standards, and information on their application, are available in the personnel office. The classification of the position may be reviewed and corrected by the agency or the U.S. Office of Personnel Management. Information on classification/job grading appeals, and complaints on exemption from FLSA, is available from the personnel office or the U.S. Office of Personnel Management.
25. Description of Major Duties and Responsibilities (See Attached)
23. Position Review Initials Date Initials Date Initials Date Initials Date
a. Employee (optional)
b. Supervisor
c. Classifier
Initials Date
24. Remarks
NSN 7540-00-634-4265 Previous Edition Usable 5008-106 OF 8 (Rev. 1-85) U.S. Office of Personnel Management FPM Chapter 295
4. Employing Office Location
Field
Nonexempt No
Date
New
Other
Date
Optional Form 8 (BACK) (Revised 1/85)
Instructions for Completing Optional Form 8 POSITION DESCRIPTION
In order to comply with the requirements of FPM Chapter 295, subchapter 3, and other provisions of the FPM, agencies must complete the items marked by an asterisk. Agencies may determine what other items are to be used.
• A "Supervisory" position is one that meets the requirements for a supervisory title as set forth in current OPM classification and job-grading guidance. Agencies may designate first-level supervisory positions by placing "1" or "1st" after "Supervisory."
• A "Managerial" position is one that meets the requirements for such a designation as set forth in current OPM classification guidance.
*1. Enter position number used by the agency for control purposes. See FPM Chapter 312, Subchapter 3.
3. Check one.*4. Enter geographical location by city and State (or if position is in a
foreign country, by city and country).
*5. Enter geographical location if different from that of #4.
6. To be completed by OPM when certifying positions. (See Item 15 for date of OPM certification.) For SES and GS-16/18 positions and equivalent, show the position number used on OPM Form 1390 (e.g., DAES0012).
*7. Check one to show whether the incumbent is exempt or nonexempt from the minimum wage and overtime provisions of the Fair Labor Standards Act. See FPM Chapter 551.
8. Check box if statement is required. See FPM Chapter 734 for the Executive Personnel Financial Disclosure Report, SF 278. See FPM Chapter 735, Subchapter 4, for the Employment and Financial Interests Statement.
9. Check one to show whether Identical Additional positions are permitted. See FPM Chapter 312, Subchapter 4. Agencies may show the number of such positions authorized and/or established after the "Yes" block.
10. Check one. See FPM Chapter 212 for information on the competitive service and FPM Chapter 213 for the excepted service. For a position in the excepted service, enter authority for the exception, e.g., "Schedule A-213.3102(d)" for Attorney positions excepted under Schedule A of the Civil Service Regulations. SES (Gen) stands for a General position in the Senior Executive Service, and SES (CR) stands for a Career Reserved position.
11. Check one.
12. Check one to show whether the position is non-sensitive, noncritical sensitive, critical sensitive, or special sensitive for security purposes. If this is an ADP position, write the letter "C" beside the sensitivity.
• For "Official Title of Position," see the applicable classification or job grading standard. For positions not covered by a published standard, see the General Introduction to "Position Classification Standards," Section III, for GS positions, or FPM Supplement 512-1, "Job Grading System for Trades and Labor Occupations," Part 1, Section III.
• For "Pay Plan code, see FPM Supplement 292-1, "Personnel Data Standards," Book III.
• For "Occupational Code," see the applicable standard; or, where no standard has been published, see the "Handbook of Occupational Groups and Series of Classes" for GS positions, or FPM Supplement 512-1, Part 3, for trades and labor positions. For all positions in scientific and engineering occupations, enter the two-digit functional classification code in parentheses immediately following the occupational code, e.g., "GS-1310(14)." The codes are listed and discussed in the General Introduction to "Position Classification Standards," Section VI.
13. Enter competitive level code for use in reduction-in-force actions.See FPM Chapter 351.
14. Agencies may use this block for any additional coding requirement.
*15. Enter classification/job grading action.
16. Enter the organizational, functional, or working title if it differs from the official title.
17. Enter the name of the incumbent. If there is no incumbent, enter "vacancy."
*18. Enter the organizational location of the position, starting with the name of the department or agency and working down from there.
19. If the position is occupied, have the incumbent read the attached description of duties and responsibilities. The employee's signature is optional.
*20. This statement normally should be certified by the immediate supervisor of the position. At its option, an agency may also have a higher-level supervisor or manager certify the statement.
*21. This statement should be certified by the agency official who makes the classification/job grading decision. Depending on agency regulations, this official may be a personnel office representative, or a manager or supervisor delegated classification/job grading authority.
22. Enter the position classification/job grading standard(s) used and the date of issuance, e.g., "Mail and File, GS-305, May 1977."
23. Agencies are encouraged to review periodically each established position to determine whether the position is still necessary and, if so, whether the position description is adequate and classification/job grading is proper. See FPM Letter 536-1 (to be incorporated into FPM Chapter 536). This section may be used as part of the review process. The employee's initials are optional. The initials by the supervisor and classifier represent recertifications of the statements in items #20 and #21 respectively.
24. This section may be used by the agency for additional coding requirements or for any appropriate remarks.
*25. Type the description on plain bond paper and attach to the form. The agency position number should be shown on the attachment. See appropriate instructions for format of the description and for any requirements for evaluation documentation, e. g., "Instructions for the Factor Evaluation System," in the General Introduction to "Position Classification Standards," Section VII.
• "Redescription" means the duties and/or responsibilities of an existing position are being changed.
• "New" means the position has not previously existed. • "Reestablishment" means the position previously existed, but
had been cancelled. • "Other" covers such things as change in title or occupational
series without a change in duties or responsibilities. • The "Explanation" section should be used to show the reason if
"Other" is checked, as well as any position(s) replaced by position number, title, pay plan, occupational code, and grade.
*2. Check one.
Recommended