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

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     Indian Health Manual

Part 7, Chapter 8:  Manual Exhibit 7-8-A

Sample Service Agreement

Employee Name Date
1.  Required Service Period With Organization

_____Years _____Months

(6 months to 4 years)
2.  Commencement Date of Service Period

Termination Date of Service Period
3.  Probationary or Training Period Required Before Payment?

_____ Yes _____No
4.  Payment of Incentive

$_____ _____%

Method of Payment
  1. Lump sum
  2. Installments by pay period
  3. Installments by service period (describe)
  4. Combination of the above
5.  Conditions for Terminating Service Agreement
(Check all that apply)
  1. Demotion of Separation for Cause_____
  2. Rating of Record less than Fully Successful_______
  3. Failure to Fulfill Terms of Service Agreement_____
6.  Conditions Under Which Employee Must Repay Incentive (Describe)
7.  Conditions Under Which Organization May Terminate the Service Agreement for Failure to Complete Service Period 8.  Conditions Under Which Organization Will Pay an Additional Incentive Payment for Partially Completed Service if a Service Agreement is Terminated.

9.  Other Terms or Conditions Resulting in the Termination of the Service Agreement 10.  Criteria for Repayment of an Incentive for Failure to Complete the Specified Length of Service (see Section 575.1 - 60(C)

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