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pdfOMB Approved No. 2900-0524
Respondent Burden: 10 Minutes
VA POLICE OFFICER PRE-EMPLOYMENT SCREENING CHECKLIST
PRIVACY ACT STATEMENT: The information provided on VA Form 0120 will be confidential and protected by the Privacy Act of 1994 (5 U.S.C. 522a) and the
VA's Confidentiality statue (38 U.S.C. 5701) as implemented by 38 CFR 1.576(b). Assurances of confidentiality are provided in the system of records identified as
"Personnel Investigation Records, OPM/Central 9."
RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to this collection of information unless it displays a valid
OMB Control Number. The information requested is approved under OMB Control Number 2900-0524, and is necessary to accomplish the pre-employment screening
to determine the qualification and suitability of the applicant to be hired as a VA police officer. This information is solicited under authority of Title 38, United States
Code. Responding to this collection of information is voluntary and failure to furnish this information will have no other adverse effect.
Public reporting burden for this collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspects of this collection, including suggestions for reducing this burden to VA Clearance Officer (005E3), 810 Vermont Ave., Washington, DC 20420. SEND
COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUEST FOR BENEFITS TO THIS ADDRESS.
FACILITY LOCATION
FBI ORI.
PART I - APPLICANT
A. LAST NAME, FIRST NAME, MIDDLE INITIAL
B. SOCIAL SECURITY NO.
C. DATE OF BIRTH
D. SEX
PART II - ARREST RECORD CHECKS AND CERTIFICATION - BY CHIEF OF POLICE (Purpose Code: Criminal Justice Employment)
A. CHECK CRIMINAL RECORD REPOSITORY
STATES CHECKED
B. CHECK OF F.B.I. NATIONAL CRIME INFORMATION CENTER
NO RECORD
NO RECORD
RECORD (Attach explanation of
charges and disposition)
RECORD (Attach explanation of charges and disposition)
CERTIFICATION: I have reviewed the application and the above candidate has the type of experience that provided the knowledge, skills, and abilities to
successfully perform the duties of a VA police officer.
SIGNATURE OF CHIEF OF POLICE
DATE
Submit by Email to your local HR Mana
PART III - TELEPHONE CHECKS (Human Resources Management)
INSTRUCTIONS: Determine quality of work history for all employment within the past 5 years. Verify all employment used for qualifiction regardless of age.
A
B
C
1. NAME OF EMPLOYER
2. NAME AND TITLE OF CONTACT
3. DID APPLICANT'S DUTIES INCLUDE
PROTECTION OF PERSONS & PROP.
4. INCLUSIVE DATES OF
EMPLOYMENT
5. NUMBER OF HOURS PER WEEK
6. WAS APPLICANT'S QUALITY OF
WORK SATISFACTORY?
7. WAS APPLICANT'S HONESTY AND
CHARACTER SATISFACTORY?
8. APPLICANT'S REASON FOR
LEAVING
9. WOULD YOU REHIRE APPLICANT?
SIGNATURE AND TITLE
OF INQUIRER
DATE
PART IV - BASIS FOR QUALIFICATION AND CERTIFICATION (Human Resources Management)
ACCEPTABLE JOB EXPERIENCE MEETING GS-083 MINIMUM QUALIFICATION REQUIREMENTS.
ACCEPTABLE SUBSTITUTE EDUCATION EVIDENCED BY TRANSCRIPT COPY.
______ YEARS ACTIVE MILITARY SERVICE IN THE QUALIFYING SPECIALTY OF:
ARMY:
MARINE CORPS:
AIR FORCE:
95B
95C
31A
31B
5805
5811
5812
5813
5814
5821
08111-114
81110
81170
81172
81130
81150
81112
81132
81152
81199
3P1-4
3P011
3P031
3P051
3P071
3P091
75011
75031
75051
75071
5803
75091
(No code)
9545
0000MA
NAVY:
COAST GUARD:
Military service in the above checked specialty verified by review of DD Form 214, Certificate of Release of Discharge from Active Duty or other official
document. (If other specify: ________________________________________________.)
CERTIFICATION: Human Resources Management Service certifies that the applicant is suitable and meets current qualification standards for the GS-083 Police Officer
series. Telephone interviews have been satisfactorily completed and documented in Part III of this form.
SIGNATURE AND TITLE
OF VERIFIER
VA FORM
MAY 2009
0120
DATE
Submit by Email
1 - VA POLICE INVESTIGATIVE RECORDS FILE (OPM/Cntral 9)
OMB Approved No. 2900-0524
Respondent Burden: 10 Minutes
VA POLICE OFFICER PRE-EMPLOYMENT SCREENING CHECKLIST
PRIVACY ACT STATEMENT: The information provided on VA Form 0120 will be confidential and protected by the Privacy Act of 1994 (5 U.S.C. 522a) and the
VA's Confidentiality statue (38 U.S.C. 5701) as implemented by 38 CFR 1.576(b). Assurances of confidentiality are provided in the system of records identified as
"Personnel Investigation Records, OPM/Central 9."
RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to this collection of information unless it displays a valid
OMB Control Number. The information requested is approved under OMB Control Number 2900-0524, and is necessary to accomplish the pre-employment screening
to determine the qualification and suitability of the applicant to be hired as a VA police officer. This information is solicited under authority of Title 38, United States
Code. Responding to this collection of information is voluntary and failure to furnish this information will have no other adverse effect.
Public reporting burden for this collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspects of this collection, including suggestions for reducing this burden to VA Clearance Officer (005E3), 810 Vermont Ave., Washington, DC 20420. SEND
COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUEST FOR BENEFITS TO THIS ADDRESS.
FACILITY LOCATION
FBI ORI.
PART I - APPLICANT
A. LAST NAME, FIRST NAME, MIDDLE INITIAL
B. SOCIAL SECURITY NO.
C. DATE OF BIRTH
D. SEX
PART II - ARREST RECORD CHECKS AND CERTIFICATION - BY CHIEF OF POLICE (Purpose Code: Criminal Justice Employment)
A. CHECK CRIMINAL RECORD REPOSITORY
B. CHECK OF F.B.I. NATIONAL CRIME INFORMATION CENTER
STATES CHECKED
NO RECORD
NO RECORD
RECORD (Attach explanation of
charges and disposition)
RECORD (Attach explanation of charges and disposition)
CERTIFICATION: I have reviewed the application and the above candidate has the type of experience that provided the knowledge, skills, and abilities to
successfully perform the duties of a VA police officer.
SIGNATURE OF CHIEF OF POLICE
DATE
Submit by Email to your
local HR Management
PART III - TELEPHONE CHECKS (Human Resources Management)
INSTRUCTIONS: Determine quality of work history for all employment within the past 5 years. Verify all employment used for qualifiction regardless of age.
A
B
C
1. NAME OF EMPLOYER
2. NAME AND TITLE OF CONTACT
3. DID APPLICANT'S DUTIES INCLUDE
PROTECTION OF PERSONS & PROP.
4. INCLUSIVE DATES OF
EMPLOYMENT
5. NUMBER OF HOURS PER WEEK
6. WAS APPLICANT'S QUALITY OF
WORK SATISFACTORY?
7. WAS APPLICANT'S HONESTY AND
CHARACTER SATISFACTORY?
8. APPLICANT'S REASON FOR
LEAVING
9. WOULD YOU REHIRE APPLICANT?
SIGNATURE AND TITLE
OF INQUIRER
DATE
PART IV - BASIS FOR QUALIFICATION AND CERTIFICATION (Human Resources Management)
ACCEPTABLE JOB EXPERIENCE MEETING GS-083 MINIMUM QUALIFICATION REQUIREMENTS.
ACCEPTABLE SUBSTITUTE EDUCATION EVIDENCED BY TRANSCRIPT COPY.
______ YEARS ACTIVE MILITARY SERVICE IN THE QUALIFYING SPECIALTY OF:
ARMY:
MARINE CORPS:
AIR FORCE:
95B
95C
31A
31B
5803
5805
5811
5812
5813
5814
5821
08111-114
81110
81170
81172
81130
81150
81112
81132
81152
81199
3P1-4
3P011
3P031
3P051
3P071
3P091
75011
75031
75051
75071
75091
(No code)
9545
0000MA
NAVY:
COAST GUARD:
Military service in the above checked specialty verified by review of DD Form 214, Certificate of Release of Discharge from Active Duty or other official
document. (If other specify: ________________________________________________.)
CERTIFICATION: Human Resources Management Service certifies that the applicant is suitable and meets current qualification standards for the GS-083 Police Officer
series. Telephone interviews have been satisfactorily completed and documented in Part III of this form.
SIGNATURE AND TITLE
OF VERIFIER
VA FORM
MAY 2009
0120
DATE
Submit by Email
2 - Photocopy to VA Law Enforcement Training Center (Little Rock, AR)
| File Type | application/pdf |
| File Modified | 2009-05-28 |
| File Created | 2009-05-28 |