0990-0433 OF306AddendumToDeclarationForFederalEmployment

OMB Approved
Form No. 0917-0028
Expiration Date: 11/30/2018

Addendum to Declaration for Federal Employment (OF 306)
Indian Health Service
Child Care & Indian Child Care Worker Positions
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Item 16. Agency Specific Questions
Name: ___________________________

Social Security Number: __________________

(Please print)

Job Title in Announcement: ____________________ Announcement Number: ___________
Section 231 of the Crime Control Act of 1990, Public Law (Pub. L.) 101-647, requires
employment applications for individuals seeking employment in a position involved with the
provision to children under the age of 18 of “child care services,” as defined in
42 U.S.C. § 13041(a)(2), 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.
Under 42 U.S.C. § 13041(a)(2), the term "child care services" means child protective services
(including the investigation of child abuse and neglect reports), social services, health and mental
health care, child (day) care, education (whether or not directly involved in teaching), foster care,
residential care, recreational or rehabilitative programs, and detention, correctional, or treatment
services. Individuals hired for such positions must undergo a criminal history background check.
Section 408 of the Indian Child Protection and Family Violence Prevention Act,
Pub. 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 agency
must ensure that persons hired for these positions have not been found guilty of or pleaded nolo
contendere or guilty to certain crimes. The law requires the agency conduct an investigation of
the character of each individual who is being considered for employment in such a position and
prescribe in regulations the “minimum standards of character” that must be met in order for an
individual to fill such a position. The regulations specify that “[t]he minimum standards of
character shall be considered met only after the individual has been the subject of a satisfactory
background investigation,” which includes a criminal history background check.
42 C.F.R. § 136.406.
To assure 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______
[If “YES”, 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.]

2.

Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or
guilty to, any felonious or misdemeanor offense under Federal, State, or tribal law
involving crimes of violence; sexual assault, molestation, exploitation, contact or
prostitution; or crimes against persons; or offenses committed against children?
YES______ NO______
[If “YES”, provide the date, explanation of the violation, disposition of the arrest or
charge, place of occurrence, and the name 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 fine under title 18 of the U.S. Code, or imprisonment of not more than five years,
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 Indian Health Service
and my right to challenge the accuracy and completeness of any information contained in the
report.
_________________________________________________________________
Applicant’s Signature (sign in ink)
Date
Public Burden Statement: In accordance with Paperwork Reduction Act [5 CFR § 1320.8 (b)(3)], a Federal agency may not conduct
or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Respondents must be informed (on the reporting instrument, in instructions, or in a cover letter) the reasons for which the
information will be collected; the way the information will be used to further the proper performance of the functions of the agency;
whether responses to the collection of the information are voluntary, required to obtain a benefit (citing authority), or mandatory
(citing authority); and the nature and extent of confidentiality to be provided, if any (citing authority). Public reporting burden for
this collection of information is estimated to average 12 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection information. Send
comments regarding the burden estimate or any other aspect of this collection of information to the IHS Information Collection
Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane,
Rockville, Mail Stop 09E70, MD 20857. Please do not send completed data collection instruments to this address.