Manual Exhibit 5-22.4-A

 ADDENDUM TO THE DECLARATION FOR FEDERAL EMPLOYMENT

Indian Health Service

Child Care and Indian Child Care Worker Positions

Name:__________________________________ Social Security Number:_________________________

 
Job Title:_________________________________ Announcement Number:__________________________

 
The “Crime Control Act of 1990,” Section 231, Public Law (P.L.) 101-647, requires that employment application for Federal child care positions contain a question asking whether the individual has ever been arrested for or charged with a crime involving a child and for the disposition of the arrest or charge.

The “Miscellaneous Indian Legislation,” Section 408, P.L. 101-630, contains a related requirement for positions in the Department of Health and Human Services that involve regular contact with or control over Indian children. The Indian Health Service (IHS) must ensure that individuals hired for these positions have not been found guilty of or pleaded nolo contendere to violent crimes. To ensure compliance with the above laws, the following questions are added to the declaration for Federal employment:

1.

Have you ever been arrested for or charged with a crime involving a child?
 

YES:_______________          NO: __________________
2.

Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to, any offense under Federal, State, or Tribal law involving crimes of violence: sexual assault, molestation, exploitation, prostitution, or contact; or crimes against persons?

 

YES:_______________          NO: __________________
[If you answered “YES”, to either or both questions, please provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name and address of the police department or court involved.]

 
I certify that:

 
1.

My response to these questions is made under penalty of perjury, which is punishable by fines of up to $2,000 or 5 years imprisonment, or both; and
 
2.

I have received notice that a criminal check will be conducted .
 
I understand my right to obtain a copy of any criminal history report made available to the IHS and my right to challenge the accuracy and completeness of any information contained in the report.

 

                                                                                                             

                            

Applicant’s Signature

 Date