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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Circular Exhibit 2013-06-B



SAMPLE
INDIAN HEALTH SERVICE CLEARANCE CHECKLIST

Employee Name:
Jane B. Doe
Last 4 Digits SSN:
XXX-XX-0000
Timekeeper Number:
12345
Organization and Work Location:  Indian Health Service Office, Building, and Office Suite Number, City, State, Zip Code

___X___ Separating from Federal Government

______ Transferring to another IHS component or Federal Agency

(Specify) __________________________________________

Date of Separation or Transfer:_May 31, 2013_

Forwarding Address:

Rt. 1, Box 18

Winnebago, NE 68071

Optional: Home Phone Number

Optional: Home Email Address

Clearance Items Received Comments Accountable Office for Final
Disposition (Initials and date)
x IT Access Control Removed (Network-Email - RPMS) Y    N    N/A ____________________________________ OIT______________________

x Advanced Leave Resolved Y    N    N/A ____________________________________ DHR______________________

x PIV Card Returned Y    N    N/A ____________________________________ DAS______________________

x Non-PIV Facility Access Cards Returned Y    N    N/A ____________________________________ DAS______________________

x Keys Returned Y    N    N/A ____________________________________ DAS______________________

x Official Files/Record Returned Y    N    N/A ____________________________________ DHR______________________

x Government Purchase Card (PCard) Returned Y    N    N/A ____________________________________ DFO______________________

x Travel Card Returned Y    N    N/A ____________________________________ DFO______________________

x Outstanding Travel Advance Resolved Y    N    N/A ____________________________________ DFO______________________

x Outstanding Travel Voucher Resolved Y    N    N/A ____________________________________ DFO______________________

x E-Gov Travel Service Access Removed Y    N    N/A ____________________________________ DFO______________________

x Library Books/Card Returned Y    N    N/A ____________________________________ DAS______________________

x UFMS Access Removed Y    N    N/A ____________________________________ OFA______________________

x Government Hang Tag/Parking Sticker Returned Y    N    N/A ____________________________________ DAS______________________

x Government Phone cards Returned Y    N    N/A ____________________________________ DAS______________________

x Government Emergency Telecommunications Service (GETS) card Returned Y    N    N/A ____________________________________ DAS______________________

x Government Cell Phone Returned Y    N    N/A ____________________________________ DAS______________________

x Smart Phone, Palm Pilot, Blackberry, iPhone Returned Y    N    N/A ____________________________________ OIT/DAS__________________

x Laptop Computer Returned Y    N    N/A ____________________________________ OIT/DAS__________________

x Government Pager Returned Y    N    N/A ____________________________________ DAS______________________

x Other Goverment Furnished Equipment Returned Y    N    N/A ____________________________________ DHR______________________

x Separation Date Entered into ITAS Y    N    N/A ____________________________________ DHR______________________

x Supervisor Initiated Captial HR Appropriate Action Y    N    N/A ____________________________________ Supervisor________________

x Capital HR Request Approved Y    N    N/A ____________________________________ DHR______________________

x Action Tracking System (ATS) Access Removed Y    N    N/A ____________________________________ ESS______________________

x E-WITS Access Removed Y    N    N/A ____________________________________ DHR______________________

x PRISM Access Removed Y    N    N/A ____________________________________ DFA______________________

  • Under Comments, list the Office that was sent the item or notified about clearing it.  Accountable Offices may differ.

  • If the employee is not willing to sign the clearance sheet, not present, or deceased, the supervisor should locate all equipment assigned to the employee and account for each piece on the clearance sheet.  For any missing items take the appropriate action.

Distribution:  Completed original to the Director, Division of Human Resources or the Regional Human Resources Office
1 copy to the employee
1 copy to the supervisor

Additional Comments

I certify that I do not have IHS property or records in my possession and that I am not indebted to the IHS.

I certify that I have completed this form and that I have verified that all required clearances have been obtained.

Signature of Employee Date

Signature of Supervisor Date


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