Number range CHAPTER HHS Modifications to OPM\'s Optional Form (OF) 69

> **Assignment Agreement**

**Title IV of the**

**Intergovernmental Personnel Act of 1970**

(5 U.S.C. 3371 - 3376)

+----------------------------------+---+----------------+-----------------+
| **Instructions**                 |   |                |                 |
+----------------------------------+---+----------------+-----------------+
| This agreement constitutes the   | W |                |                 |
| written record of the            | i |                |                 |
| obligations and responsibilities | t |                |                 |
| of the parties to a temporary    | h |                |                 |
| assignment arranged under the    | i |                |                 |
| provisions of the                | n |                |                 |
| Intergovernmental Personnel Act  | 1 |                |                 |
| of 1970.                         | 5 |                |                 |
|                                  | d |                |                 |
| The term \"State or local        | a |                |                 |
| government\", when appearing on  | y |                |                 |
| this form, refers to an          | s |                |                 |
| institution of higher education, | o |                |                 |
| an Indian tribal government, and | f |                |                 |
| any other eligible organization. | t |                |                 |
|                                  | h |                |                 |
| Copies of the completed and      | e |                |                 |
| signed agreement should be       | e |                |                 |
| retained by each signatory.      | f |                |                 |
|                                  | f |                |                 |
|                                  | e |                |                 |
|                                  | c |                |                 |
|                                  | t |                |                 |
|                                  | i |                |                 |
|                                  | v |                |                 |
|                                  | e |                |                 |
|                                  | d |                |                 |
|                                  | a |                |                 |
|                                  | t |                |                 |
|                                  | e |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | g |                |                 |
|                                  | n |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | , |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | c |                |                 |
|                                  | o |                |                 |
|                                  | p |                |                 |
|                                  | y |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | i |                |                 |
|                                  | s |                |                 |
|                                  | f |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
|                                  | m |                |                 |
|                                  | m |                |                 |
|                                  | u |                |                 |
|                                  | s |                |                 |
|                                  | t |                |                 |
|                                  | b |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | t |                |                 |
|                                  | o |                |                 |
|                                  | : |                |                 |
|                                  |   |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | O |                |                 |
|                                  | f |                |                 |
|                                  | f |                |                 |
|                                  | i |                |                 |
|                                  | c |                |                 |
|                                  | e |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | I |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | g |                |                 |
|                                  | o |                |                 |
|                                  | v |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | n |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | a |                |                 |
|                                  | l |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | P |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | l |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | P |                |                 |
|                                  | r |                |                 |
|                                  | o |                |                 |
|                                  | g |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | m |                |                 |
|                                  | s |                |                 |
|                                  | > |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | O |                |                 |
|                                  | f |                |                 |
|                                  | f |                |                 |
|                                  | i |                |                 |
|                                  | c |                |                 |
|                                  | e |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | P |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | l |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | M |                |                 |
|                                  | a |                |                 |
|                                  | n |                |                 |
|                                  | a |                |                 |
|                                  | g |                |                 |
|                                  | e |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | > |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | R |                |                 |
|                                  | o |                |                 |
|                                  | o |                |                 |
|                                  | m |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | 7 |                |                 |
|                                  | H |                |                 |
|                                  | 3 |                |                 |
|                                  | 9 |                |                 |
|                                  | > |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | 1 |                |                 |
|                                  | 9 |                |                 |
|                                  | 0 |                |                 |
|                                  | 0 |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | E |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | S |                |                 |
|                                  | t |                |                 |
|                                  | r |                |                 |
|                                  | e |                |                 |
|                                  | e |                |                 |
|                                  | t |                |                 |
|                                  | , |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | N |                |                 |
|                                  | . |                |                 |
|                                  | W |                |                 |
|                                  | . |                |                 |
|                                  | > |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | W |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | h |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | g |                |                 |
|                                  | t |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | , |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | D |                |                 |
|                                  | . |                |                 |
|                                  | C |                |                 |
|                                  | . |                |                 |
|                                  | > |                |                 |
|                                  |   |                |                 |
|                                  | 2 |                |                 |
|                                  | 0 |                |                 |
|                                  | 4 |                |                 |
|                                  | 1 |                |                 |
|                                  | 5 |                |                 |
|                                  |   |                |                 |
|                                  | P |                |                 |
|                                  | r |                |                 |
|                                  | o |                |                 |
|                                  | c |                |                 |
|                                  | e |                |                 |
|                                  | d |                |                 |
|                                  | u |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | l |                |                 |
|                                  | q |                |                 |
|                                  | u |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | t |                |                 |
|                                  | i |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | c |                |                 |
|                                  | o |                |                 |
|                                  | m |                |                 |
|                                  | p |                |                 |
|                                  | l |                |                 |
|                                  | e |                |                 |
|                                  | t |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | g |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | g |                |                 |
|                                  | n |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | a |                |                 |
|                                  | g |                |                 |
|                                  | r |                |                 |
|                                  | e |                |                 |
|                                  | e |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | f |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
|                                  | m |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | o |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | p |                |                 |
|                                  | e |                |                 |
|                                  | c |                |                 |
|                                  | t |                |                 |
|                                  | s |                |                 |
|                                  | r |                |                 |
|                                  | e |                |                 |
|                                  | l |                |                 |
|                                  | a |                |                 |
|                                  | t |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | g |                |                 |
|                                  | t |                |                 |
|                                  | o |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | m |                |                 |
|                                  | o |                |                 |
|                                  | b |                |                 |
|                                  | i |                |                 |
|                                  | l |                |                 |
|                                  | i |                |                 |
|                                  | t |                |                 |
|                                  | y |                |                 |
|                                  | p |                |                 |
|                                  | r |                |                 |
|                                  | o |                |                 |
|                                  | g |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | m |                |                 |
|                                  | s |                |                 |
|                                  | h |                |                 |
|                                  | o |                |                 |
|                                  | u |                |                 |
|                                  | l |                |                 |
|                                  | d |                |                 |
|                                  | b |                |                 |
|                                  | e |                |                 |
|                                  | a |                |                 |
|                                  | d |                |                 |
|                                  | d |                |                 |
|                                  | r |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | s |                |                 |
|                                  | e |                |                 |
|                                  | d |                |                 |
|                                  | t |                |                 |
|                                  | o |                |                 |
|                                  | e |                |                 |
|                                  | i |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | m |                |                 |
|                                  | o |                |                 |
|                                  | b |                |                 |
|                                  | i |                |                 |
|                                  | l |                |                 |
|                                  | i |                |                 |
|                                  | t |                |                 |
|                                  | y |                |                 |
|                                  | p |                |                 |
|                                  | r |                |                 |
|                                  | o |                |                 |
|                                  | g |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | m |                |                 |
|                                  | c |                |                 |
|                                  | o |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
|                                  | d |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | a |                |                 |
|                                  | t |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | a |                |                 |
|                                  | c |                |                 |
|                                  | h |                |                 |
|                                  | F |                |                 |
|                                  | e |                |                 |
|                                  | d |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | l |                |                 |
|                                  | a |                |                 |
|                                  | g |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | c |                |                 |
|                                  | y |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
|                                  | t |                |                 |
|                                  | o |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | t |                |                 |
|                                  | a |                |                 |
|                                  | f |                |                 |
|                                  | f |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | h |                |                 |
|                                  | e |                |                 |
|                                  | I |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | g |                |                 |
|                                  | o |                |                 |
|                                  | v |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | n |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | a |                |                 |
|                                  | l |                |                 |
|                                  | P |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | l |                |                 |
|                                  | P |                |                 |
|                                  | r |                |                 |
|                                  | o |                |                 |
|                                  | g |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | m |                |                 |
|                                  | s |                |                 |
|                                  | D |                |                 |
|                                  | i |                |                 |
|                                  | v |                |                 |
|                                  | i |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | i |                |                 |
|                                  | n |                |                 |
|                                  | O |                |                 |
|                                  | f |                |                 |
|                                  | f |                |                 |
|                                  | i |                |                 |
|                                  | c |                |                 |
|                                  | e |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | P |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | l |                |                 |
|                                  | M |                |                 |
|                                  | a |                |                 |
|                                  | n |                |                 |
|                                  | a |                |                 |
|                                  | g |                |                 |
|                                  | e |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | \ |                |                 |
|                                  | ' |                |                 |
|                                  | s |                |                 |
|                                  | R |                |                 |
|                                  | e |                |                 |
|                                  | g |                |                 |
|                                  | i |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | a |                |                 |
|                                  | l |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | f |                |                 |
|                                  | i |                |                 |
|                                  | c |                |                 |
|                                  | e |                |                 |
|                                  | . |                |                 |
+----------------------------------+---+----------------+-----------------+
| **PART 1 - NATURE OF ASSIGNMENT  |   |                |                 |
| AGREEMENT**                      |   |                |                 |
+----------------------------------+---+----------------+-----------------+
| 1-A. Origin of Assignment        |   | 1-B. Category  |                 |
| Agreement                        |   | of Assignment  |                 |
|                                  |   | Agreement      |                 |
| New Agreement                    |   |                |                 |
|                                  |   | Regular        |                 |
| Modification of existing         |   | purpose        |                 |
| agreement                        |   | assignment as  |                 |
|                                  |   | defined in HHS |                 |
| Extension of existing agreement  |   | 334-1-30C      |                 |
|                                  |   |                |                 |
| Modification and Extension of    |   | Special        |                 |
| existing agreement               |   | purpose        |                 |
|                                  |   | assignment as  |                 |
|                                  |   | defined in     |                 |
|                                  |   | HHS-1-30D with |                 |
|                                  |   | total          |                 |
|                                  |   |                |                 |
|                                  |   | time of        |                 |
|                                  |   | assignment and |                 |
|                                  |   | extensions     |                 |
|                                  |   | limited to 4   |                 |
|                                  |   | consecutive    |                 |
|                                  |   | years          |                 |
|                                  |   |                |                 |
|                                  |   | Special        |                 |
|                                  |   | purpose        |                 |
|                                  |   | assignment as  |                 |
|                                  |   | defined in HHS |                 |
|                                  |   | 334-1-30D      |                 |
|                                  |   | which          |                 |
|                                  |   |                |                 |
|                                  |   | may be         |                 |
|                                  |   | extended       |                 |
|                                  |   | beyond 4 years |                 |
|                                  |   | as provided in |                 |
|                                  |   | P.L.98-146     |                 |
+----------------------------------+---+----------------+-----------------+
| **PART 2 - INFORMATION ON        |   |                |                 |
| PARTICIPATING EMPLOYEE**         |   |                |                 |
+----------------------------------+---+----------------+-----------------+
| 2\. Name (*Last, First, Middle)* |   |                | 3\. Social      |
|                                  |   |                | Security Number |
+----------------------------------+---+----------------+-----------------+
| 4\. Home Address *(Street, City, | 5 |                |                 |
| State, ZIP Code)*                | - |                |                 |
|                                  | A |                |                 |
|                                  | . |                |                 |
|                                  | H |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | g |                |                 |
|                                  | n |                |                 |
|                                  | e |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | v |                |                 |
|                                  | e |                |                 |
|                                  | d |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | a |                |                 |
|                                  | p |                |                 |
|                                  | r |                |                 |
|                                  | e |                |                 |
|                                  | v |                |                 |
|                                  | i |                |                 |
|                                  | o |                |                 |
|                                  | u |                |                 |
|                                  | s |                |                 |
|                                  | I |                |                 |
|                                  | P |                |                 |
|                                  | A |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | g |                |                 |
|                                  | n |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | ? |                |                 |
|                                  |   |                |                 |
|                                  | Y |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | ( |                |                 |
|                                  | c |                |                 |
|                                  | o |                |                 |
|                                  | m |                |                 |
|                                  | p |                |                 |
|                                  | l |                |                 |
|                                  | e |                |                 |
|                                  | t |                |                 |
|                                  | e |                |                 |
|                                  | 5 |                |                 |
|                                  | - |                |                 |
|                                  | B |                |                 |
|                                  | ) |                |                 |
|                                  | N |                |                 |
|                                  | o |                |                 |
|                                  | ( |                |                 |
|                                  | o |                |                 |
|                                  | m |                |                 |
|                                  | i |                |                 |
|                                  | t |                |                 |
|                                  | 5 |                |                 |
|                                  | - |                |                 |
|                                  | B |                |                 |
|                                  | ) |                |                 |
|                                  |   |                |                 |
|                                  | 5 |                |                 |
|                                  | - |                |                 |
|                                  | B |                |                 |
|                                  | . |                |                 |
|                                  | D |                |                 |
|                                  | a |                |                 |
|                                  | t |                |                 |
|                                  | e |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | f |                |                 |
|                                  | p |                |                 |
|                                  | r |                |                 |
|                                  | e |                |                 |
|                                  | v |                |                 |
|                                  | i |                |                 |
|                                  | o |                |                 |
|                                  | u |                |                 |
|                                  | s |                |                 |
|                                  | I |                |                 |
|                                  | P |                |                 |
|                                  | A |                |                 |
|                                  | a |                |                 |
|                                  | s |                |                 |
|                                  | s |                |                 |
|                                  | i |                |                 |
|                                  | g |                |                 |
|                                  | n |                |                 |
|                                  | m |                |                 |
|                                  | e |                |                 |
|                                  | n |                |                 |
|                                  | t |                |                 |
|                                  | ( |                |                 |
|                                  | s |                |                 |
|                                  | ) |                |                 |
|                                  | : |                |                 |
|                                  |   |                |                 |
|                                  | F |                |                 |
|                                  | R |                |                 |
|                                  | O |                |                 |
|                                  | M |                |                 |
|                                  | : |                |                 |
|                                  | T |                |                 |
|                                  | O |                |                 |
|                                  | : |                |                 |
+----------------------------------+---+----------------+-----------------+
| **PART 3 - PARTIES TO THE        |   |                |                 |
| AGREEMENT**                      |   |                |                 |
+----------------------------------+---+----------------+-----------------+
| 6\. Federal Agency *(List        | 7 |                |                 |
| office, bureau or organizational | \ |                |                 |
| unit which is party to the       | . |                |                 |
| agreement)*                      | E |                |                 |
|                                  | l |                |                 |
|                                  | i |                |                 |
|                                  | g |                |                 |
|                                  | i |                |                 |
|                                  | b |                |                 |
|                                  | l |                |                 |
|                                  | e |                |                 |
|                                  | N |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | - |                |                 |
|                                  | F |                |                 |
|                                  | e |                |                 |
|                                  | d |                |                 |
|                                  | e |                |                 |
|                                  | r |                |                 |
|                                  | a |                |                 |
|                                  | l |                |                 |
|                                  | C |                |                 |
|                                  | o |                |                 |
|                                  | - |                |                 |
|                                  | S |                |                 |
|                                  | p |                |                 |
|                                  | o |                |                 |
|                                  | n |                |                 |
|                                  | s |                |                 |
|                                  | o |                |                 |
|                                  | r |                |                 |
+----------------------------------+---+----------------+-----------------+
| 8\. Is assignment being made     |   |                |                 |
| through a faculty program? Yes   |   |                |                 |
| No                               |   |                |                 |
|                                  |   |                |                 |
| If yes, give name of program.    |   |                |                 |
+----------------------------------+---+----------------+-----------------+

HHS Modifications to OPM\'s Optional Form (OF) 69 Page 2

+-----------------+-----------------+-----------------+-----------------+
| **PART          |                 |                 |                 |
| 4-POSITION      |                 |                 |                 |
| DATA**          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **A.- Position  |                 |                 |                 |
| Currently       |                 |                 |                 |
| Held**          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| 9\. Employment  |                 | 10\.            | 11\. Office     |
| Office Name and |                 | Employee\'s     | Phone No.       |
| Address         |                 | Position Title  | *(Area Code)*   |
|                 |                 |                 |                 |
| *(Building,     |                 |                 |                 |
| Street, City,   |                 |                 |                 |
| State and ZIP   |                 |                 |                 |
| Code)*          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 | 12\. Immediate  |                 |
|                 |                 | Supervisor      |                 |
|                 |                 | *(Name and      |                 |
|                 |                 | Title)*         |                 |
+-----------------+-----------------+-----------------+-----------------+
| **B. Type of    |                 |                 |                 |
| Current         |                 |                 |                 |
| Appointment**   |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| 13\. Federal    |                 | 14\.            |                 |
| Employees       |                 | Non-Federal     |                 |
| *(Check         |                 | Employees       |                 |
| appropriate     |                 |                 |                 |
| box.)*          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| Career          | Indicate Grade  | Non-Federal     | Original Date   |
| Competitive     | Level           | Annual Salary   | Employed by the |
|                 |                 |                 | Non-Federal     |
| Other           |                 |                 | Organization    |
| *(Specify)*     |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **C. Position   |                 |                 |                 |
| to Which        |                 |                 |                 |
| Assignment Will |                 |                 |                 |
| Be Made**       |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| 15\. Employment |                 | 16\.            | 17\. Office     |
| Office Name and |                 | Assignee\'s     | Phone No.       |
| Address         |                 | Position Title  | *(Area Code)*   |
|                 |                 |                 |                 |
| *(Building,     |                 |                 |                 |
| Street, City,   |                 |                 |                 |
| State and ZIP   |                 |                 |                 |
| Code)*          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 | 18\. Immediate  |                 |
|                 |                 | Supervisor      |                 |
|                 |                 | *(Name and      |                 |
|                 |                 | Title)*         |                 |
+-----------------+-----------------+-----------------+-----------------+
| **PART 5-TYPE   |                 |                 |                 |
| OF ASSIGNMENT** |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| 19\. Check      |                 | 20\. Period of  |                 |
| appropriate Box |                 | Assignment      |                 |
|                 |                 | *(Month, Day,   |                 |
| On detail from  |                 | Year)*          |                 |
| a Federal       |                 |                 |                 |
| Agency          |                 | From: To:       |                 |
|                 |                 |                 |                 |
| On leave        |                 |                 |                 |
| without pay     |                 |                 |                 |
| from a Federal  |                 |                 |                 |
| Agency          |                 |                 |                 |
|                 |                 |                 |                 |
| On detail to a  |                 |                 |                 |
| Federal Agency  |                 |                 |                 |
|                 |                 |                 |                 |
| On appointment  |                 |                 |                 |
| in a Federal    |                 |                 |                 |
| Agency          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **PART 6-REASON |                 |                 |                 |
| FOR MOBILITY    |                 |                 |                 |
| ASSIGNMENT**    |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| 21\. Indicate   |                 |                 |                 |
| the reasons for |                 |                 |                 |
| this mobility   |                 |                 |                 |
| assignment and  |                 |                 |                 |
| discuss how the |                 |                 |                 |
| work will       |                 |                 |                 |
| benefit the     |                 |                 |                 |
| participating   |                 |                 |                 |
| Federal and     |                 |                 |                 |
| non-Federal     |                 |                 |                 |
| co-sponsoring   |                 |                 |                 |
| organizations.  |                 |                 |                 |
| In addition,    |                 |                 |                 |
| indicate how    |                 |                 |                 |
| the employee\'s |                 |                 |                 |
| newly acquired  |                 |                 |                 |
| skills will be  |                 |                 |                 |
| utilized at the |                 |                 |                 |
| completion of   |                 |                 |                 |
| this            |                 |                 |                 |
| assignment.     |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+

HHS Modifications to OPM\'s Optional Form (OF) 69 Page 3

+-------------------------+--------------------------------------------+
| **PART 7-POSITION       |                                            |
| DESCRIPTION**           |                                            |
+-------------------------+--------------------------------------------+
| 22-A. Unclassified      |                                            |
| duties described below  |                                            |
| approximate level of    |                                            |
| difficulty of duties of |                                            |
| permanent assignment:   |                                            |
|                         |                                            |
| 22-B. A classified      |                                            |
| description of duties   |                                            |
| is attached for:        |                                            |
|                         |                                            |
| > LWOP/appointment      |                                            |
| > assignment            |                                            |
| >                       |                                            |
| > detail assignment     |                                            |
| > significantly         |                                            |
| > different from duties |                                            |
| > of permanent          |                                            |
| > assignment            |                                            |
+-------------------------+--------------------------------------------+
| **PART 8-EMPLOYEE       |                                            |
| BENEFITS**              |                                            |
+-------------------------+--------------------------------------------+
| 23\. Rate of Annual     | 25-A. Annual leave benefits for which      |
| Basic Pay: \$ (12 mos.) | assigned employee is eligible:             |
|                         |                                            |
| 24\. Special Pay        | 25-B. Sick leave benefits for which        |
| Conditions:             | assigned employee is eligible:             |
|                         |                                            |
| > Routine adjustments   | 25-C. Official authorized to approve       |
| > in salary (applying   | annual or sick leave:                      |
| > to all employees, or  |                                            |
| > to individual         | 25-D. Periodic time and attendance reports |
| > employees after a     | to be provided by telephone, and written   |
| > prescribed length of  | confirmation to follow:                    |
| > service, or as a      |                                            |
| > merit pay adjustment  | Every: (not applicable)                    |
| > for this assignee)    |                                            |
| > and benefit costs     | 25-E. Co-Sponsor officials designated to   |
| > will be reported on   | communicate time and attendance            |
| > quarterly or other    | information:                               |
| > periodic billing      |                                            |
| > between co-sponsors   |                                            |
| > and shared at the     |                                            |
| > established           |                                            |
| > cost-sharing ratio    |                                            |
| > for that category     |                                            |
| > without a revision of |                                            |
| > this agreement        |                                            |
| > document.             |                                            |
|                         |                                            |
| Other:                  |                                            |
+-------------------------+--------------------------------------------+
| **Designated Reporter   |                                            |
| Designated Report       |                                            |
| Receiver**              |                                            |
|                         |                                            |
| Name:                   |                                            |
|                         |                                            |
| Title:                  |                                            |
|                         |                                            |
| Telephone:              |                                            |
|                         |                                            |
| Address:                |                                            |
+-------------------------+--------------------------------------------+

HHS Exhibit 334-1-B HHS Modifications of 6/84 to OPM\'s (OF) 69 of 9/79
Page B-4

Personnel Manual

+------------------------------------------------+----------+----------+
| 25-F. Determination of post-assignment         |          |          |
| financial adjustment for annual leave accrued  |          |          |
| versus annual leave used:                      |          |          |
|                                                |          |          |
| Employer co-sponsors agree that assignee will  |          |          |
| accrue and use annual leave as needed with no  |          |          |
| post-assignment financial adjustment           |          |          |
|                                                |          |          |
| Employer co-sponsors agree that                |          |          |
| post-assignment settlement for annual leave    |          |          |
| accrued versus annual leave used will be made  |          |          |
|                                                |          |          |
| (see Exhibit 334-1-C)                          |          |          |
+------------------------------------------------+----------+----------+
| **PART 9-FISCAL OBLIGATIONS**                  |          |          |
+------------------------------------------------+----------+----------+
| 26\. Determine the relative benefit accruing   |          |          |
| to each co-sponsoring organization based on    |          |          |
| the Assignment Purposes listed below. Place a  |          |          |
| number in the boxes under the beneficiary as   |          |          |
| follows:                                       |          |          |
|                                                |          |          |
| -2- Principal Purpose(s)                       |          |          |
|                                                |          |          |
| -1- Lesser Purpose(s)                          |          |          |
|                                                |          |          |
| -0- Not Applicable                             |          |          |
+------------------------------------------------+----------+----------+
| PRINCIPAL PURPOSES OF THE ASSIGNMENT           | FEDERAL  | > NON    |
|                                                |          | -FEDERAL |
+------------------------------------------------+----------+----------+
| Developmental Opportunity for Assignee         |          |          |
| (benefits sending co-sponsor)                  |          |          |
|                                                |          |          |
| Supports Agency Mission (benefits sending      |          |          |
| co-sponsor)                                    |          |          |
|                                                |          |          |
| Supports Government-wide Initiatives (benefits |          |          |
| Federal co-sponsor)                            |          |          |
|                                                |          |          |
| Strengthens Intergovernmental Relations        |          |          |
| (benefits both)                                |          |          |
|                                                |          |          |
| Meets Temporary Need for Skilled Personnel     |          |          |
| (benefits receiving co-sponsor)                |          |          |
|                                                |          |          |
| Share Scarce Expertise (benefits receiving     |          |          |
| co-sponsor)                                    |          |          |
|                                                |          |          |
| Assists in the Transfer of new Ideas and       |          |          |
| Technology (benefits receiving co-sponsor)     |          |          |
|                                                |          |          |
| Other (Please state)                           |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
|                                                |          |          |
+------------------------------------------------+----------+----------+
| [COMPUTE BENEFIT RATIO]{.underline} TOTALS (A) |          |          |
| (B)                                            |          |          |
|                                                |          |          |
| On the basis of 100% determine what percentage |          |          |
| of the benefits from the assignment will be    |          |          |
| received by each co-sponsoring organization    |          |          |
|                                                |          |          |
| (e.g., Federal 40%/Non-Federal 60%):           |          |          |
|                                                |          |          |
| 1\. Add (A) to (B) = (C)                       |          |          |
|                                                |          |          |
| 2\. Divide A by C = % Benefit to Federal       |          |          |
|                                                |          |          |
| 3\. Divide B by C = % Benefit to Non-Federal   |          |          |
+------------------------------------------------+----------+----------+

+-----------------------------+---------+---------+---------+----------+
| 27-A. Cost-Sharing of       | Total   | Federal | Total   | Ratio    |
| Salary and Allowable        | Costs   | Share   | Non-    |          |
| Expenses                    |         |         | Federal |          |
|                             |         |         | Share   |          |
| (At rates of first day of   |         |         |         |          |
| assignment/extension)       |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| \*Annual Salary (or monthly | \$      | \$      | \$      | /        |
| salary annualized)          |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| \*Annual Employee Benefit   | \$      | \$      | \$      | /        |
| Costs (retirement, etc.)    |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| Total Annualized Salary &   | \$      | \$      | \$      | /        |
| Benefit Costs               |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| \*\*Length of Assignment    | > X     |         |         |          |
| Multiplier                  |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| Salary and Benefit Cost     | \$      | \$      | \$      | /        |
| over Assignment Period      |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| \*\*\*Federally Authorized  | \$      | \$      | \$      | /        |
| Relocation Expenses         |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| Pre-Assignment Calculation  | \$      | \$      | \$      | /        |
| of Assignments Cost         |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+
| Salary and benefit cost are |         |         |         |          |
| arbitrarily those as of the |         |         |         |          |
| first day of the proposed   |         |         |         |          |
| assignment or extension     |         |         |         |          |
| (adjustments for changes in |         |         |         |          |
| pay and benefits during     |         |         |         |          |
| assignment are recorded in  |         |         |         |          |
| Block 24).                  |         |         |         |          |
|                             |         |         |         |          |
| \*\* Examples: 2 year would |         |         |         |          |
| be: ***X 2*** 8 months      |         |         |         |          |
| would be: *X .67* 1 full    |         |         |         |          |
| year would be: ***X 1***    |         |         |         |          |
|                             |         |         |         |          |
| \*\*\* Return trip costs at |         |         |         |          |
| end of assignment are       |         |         |         |          |
| arbitrarily those of        |         |         |         |          |
| initial relocation unless a |         |         |         |          |
| different method of return  |         |         |         |          |
| is planned (exclude         |         |         |         |          |
| expected job related travel |         |         |         |          |
| expenses during assignment  |         |         |         |          |
| period which assignee will  |         |         |         |          |
| bill to gaining co-sponsor  |         |         |         |          |
| in the same manner as other |         |         |         |          |
| employees of the gaining    |         |         |         |          |
| co-sponsor)                 |         |         |         |          |
+-----------------------------+---------+---------+---------+----------+

> HHS Modifications to OPM\'s Optional Form (OF) 69 Page 5

+-----------------------------------------------------------------------+
| > 27-B. Determination of Need for Variance Approval **Federal         |
| > Non-Federal**                                                       |
| >                                                                     |
| > Benefit Ratio (last line from Block 26) **/**                       |
| >                                                                     |
| > Cost-Sharing Commitments (last line from Block 27-A.) /             |
| >                                                                     |
| > Federal costs are the same or less than the estimated Federal       |
| > benefit (go to block 27-D)                                          |
| >                                                                     |
| > Federal costs exceed the estimated Federal benefit                  |
| >                                                                     |
| > variance approval not required for Special Purpose Assignment as    |
| > defined in HHS                                                      |
| >                                                                     |
| > 334-1-30D (go to Block 27-D)                                        |
| >                                                                     |
| > justification for variance                                          |
+-----------------------------------------------------------------------+
| > 27-C. Benefit Ratio/Cost-Sharing Ratio Variance Approval required   |
| > (see 45) not required                                               |
+-----------------------------------------------------------------------+
| > 27-D. Officials responsible for carrying out financial terms of     |
| > agreement:                                                          |
| >                                                                     |
| > Federal Non-Federal                                                 |
| >                                                                     |
| > Name:                                                               |
| >                                                                     |
| > Title:                                                              |
| >                                                                     |
| > Telephone:                                                          |
| >                                                                     |
| > Address:                                                            |
+-----------------------------------------------------------------------+
| > 27-E. Frequency and method by which co-sponsors will bill and pay   |
| > costs to be shared:                                                 |
+-----------------------------------------------------------------------+
| > **PART 10-CONFLICTS OF INTEREST AND EMPLOYEE CONDUCT**              |
+-----------------------------------------------------------------------+
| > 28\. Applicable Federal, State or local conflict of interest laws   |
| > have been reviewed with the employee to assure that conflict of     |
| > interest situations do not inadvertently arise during this          |
| > assignment.                                                         |
| >                                                                     |
| > 29\. The employee has been notified of laws, rules and regulations, |
| > and policies on employee conduct which apply to him/her while on    |
| > this                                                                |
| >                                                                     |
| > assignment.                                                         |
+-----------------------------------------------------------------------+

> HHS Modifications to OPM\'s Optional Form (OF) 69 Page 6

+-------------------------------------+---+-------+-------+-------+-------+
| > **PART 11-OPTIONS**               |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > 30\. Federal Benefits Options     |   | > **  | *     | **    | >     |
|                                     |   | Requi | *Elec | Decli | **Not |
|                                     |   | red** | ted** | ned** | > Ap  |
|                                     |   |       |       |       | plica |
|                                     |   |       |       |       | ble** |
+-------------------------------------+---+-------+-------+-------+-------+
| > A. Federal Employees Group Life   |   |       |       |       |       |
| > Insurance (FEGLI)                 |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > Basic Coverage                    |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > Option A                          |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > Option B x1 x2 x3 x4 x5           |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > Option C                          |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > B-1. Federal Civil Service        |   |       |       |       |       |
| > Retirement                        |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > B-2. Federal Withholding for      |   |       |       |       |       |
| > Medicare Only (Federal employees) |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > B-3. Payroll Withholding for      |   |       |       |       |       |
| > (all) Social Security Programs    |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > C. Federal Employee Health        |   |       |       |       |       |
| > Benefits                          |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > D. TOTAL Federal Government       |   | > \$  |       |       |       |
| > Employer Costs (to be carried to  |   |       |       |       |       |
| > Block 27-A, line 2, first column) |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| 31\. Non-Federal Benefit Options    | * |       |       | **    |       |
|                                     | * |       |       | Annua |       |
|                                     | P |       |       | lized |       |
|                                     | a |       |       | Costs |       |
|                                     | y |       |       | (to   |       |
|                                     | P |       |       | e     |       |
|                                     | e |       |       | mploy |       |
|                                     | r |       |       | er)** |       |
|                                     | i |       |       |       |       |
|                                     | o |       |       |       |       |
|                                     | d |       |       |       |       |
|                                     | C |       |       |       |       |
|                                     | o |       |       |       |       |
|                                     | s |       |       |       |       |
|                                     | t |       |       |       |       |
|                                     | * |       |       |       |       |
|                                     | * |       |       |       |       |
|                                     |   |       |       |       |       |
|                                     | * |       |       |       |       |
|                                     | * |       |       |       |       |
|                                     | ( |       |       |       |       |
|                                     | t |       |       |       |       |
|                                     | o |       |       |       |       |
|                                     | e |       |       |       |       |
|                                     | m |       |       |       |       |
|                                     | p |       |       |       |       |
|                                     | l |       |       |       |       |
|                                     | o |       |       |       |       |
|                                     | y |       |       |       |       |
|                                     | e |       |       |       |       |
|                                     | r |       |       |       |       |
|                                     | ) |       |       |       |       |
|                                     | * |       |       |       |       |
|                                     | * |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| **TOTAL (to be carried to Block     |   |       |       | \$    |       |
| 27-A, line 2, first column)**       |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > 32\. Other Benefits *(Indicate    |   |       |       |       |       |
| > any other employee benefits to be |   |       |       |       |       |
| > made part of this agreement)*     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > **PART 12-TRAVEL AND              |   |       |       |       |       |
| > TRANSPORTATION EXPENSES AND       |   |       |       |       |       |
| > ALLOWANCES**                      |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
| > 33-A. Travel and transportation   |   |       |       |       |       |
| > expenses (including movement of   |   |       |       |       |       |
| > household goods) to and from the  |   |       |       |       |       |
| > assignment, or per diem           |   |       |       |       |       |
| > allowances in lieu of movement of |   |       |       |       |       |
| > household goods; how expenses     |   |       |       |       |       |
| > will be billed and paid or        |   |       |       |       |       |
| > reimbursed:                       |   |       |       |       |       |
| >                                   |   |       |       |       |       |
| > TOTAL Allowable Costs (to be      |   |       |       |       |       |
| > carried to Block 27-A, line 5,    |   |       |       |       |       |
| > first column) \$                  |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+
|                                     |   |       |       |       |       |
+-------------------------------------+---+-------+-------+-------+-------+

> HHS Modifications to OPM\'s Optional Form (OF) 69 Page 7

+-------+-----+--------------------------------------------------------+
| >     |     |                                                        |
| 33-B. |     |                                                        |
| >     |     |                                                        |
| Other |     |                                                        |
| > tr  |     |                                                        |
| avel, |     |                                                        |
| >     |     |                                                        |
| trans |     |                                                        |
| porta |     |                                                        |
| tion, |     |                                                        |
| > me  |     |                                                        |
| eting |     |                                                        |
| > or  |     |                                                        |
| >     |     |                                                        |
| confe |     |                                                        |
| rence |     |                                                        |
| >     |     |                                                        |
| atten |     |                                                        |
| dance |     |                                                        |
| >     |     |                                                        |
| cost, |     |                                                        |
| >     |     |                                                        |
|  etc. |     |                                                        |
| > for |     |                                                        |
| >     |     |                                                        |
| which |     |                                                        |
| > ass |     |                                                        |
| ignee |     |                                                        |
| >     |     |                                                        |
|  will |     |                                                        |
| > be  |     |                                                        |
| >     |     |                                                        |
|  supp |     |                                                        |
| orted |     |                                                        |
| > or  |     |                                                        |
| > r   |     |                                                        |
| eimbu |     |                                                        |
| rsed, |     |                                                        |
| > and |     |                                                        |
| >     |     |                                                        |
| which |     |                                                        |
| >     |     |                                                        |
| >     |     |                                                        |
| co-sp |     |                                                        |
| onsor |     |                                                        |
| >     |     |                                                        |
|  will |     |                                                        |
| >     |     |                                                        |
|  reim |     |                                                        |
| burse |     |                                                        |
| > or  |     |                                                        |
| > su  |     |                                                        |
| pport |     |                                                        |
| > d   |     |                                                        |
| uring |     |                                                        |
| > p   |     |                                                        |
| eriod |     |                                                        |
| > of  |     |                                                        |
| >     |     |                                                        |
| assig |     |                                                        |
| nment |     |                                                        |
| > (   |     |                                                        |
| guara |     |                                                        |
| nteed |     |                                                        |
| > to  |     |                                                        |
| > ass |     |                                                        |
| ignee |     |                                                        |
| > but |     |                                                        |
| > NOT |     |                                                        |
| > c   |     |                                                        |
| ost-s |     |                                                        |
| hared |     |                                                        |
| > by  |     |                                                        |
| > co  |     |                                                        |
| -spon |     |                                                        |
| sors) |     |                                                        |
+-------+-----+--------------------------------------------------------+
| > *   |     |                                                        |
| *PART |     |                                                        |
| >     |     |                                                        |
|  13 - |     |                                                        |
| > APP |     |                                                        |
| LICAB |     |                                                        |
| ILITY |     |                                                        |
| > OF  |     |                                                        |
| > R   |     |                                                        |
| ULES, |     |                                                        |
| > R   |     |                                                        |
| EGULA |     |                                                        |
| TIONS |     |                                                        |
| > AND |     |                                                        |
| >     |     |                                                        |
| POLIC |     |                                                        |
| IES** |     |                                                        |
+-------+-----+--------------------------------------------------------+
| >     |     |                                                        |
|  34\. |     |                                                        |
| >     |     |                                                        |
| Check |     |                                                        |
| > A   |     |                                                        |
| pprop |     |                                                        |
| riate |     |                                                        |
| >     |     |                                                        |
| Boxes |     |                                                        |
+-------+-----+--------------------------------------------------------+
| > Yes |     | A.  The rules and policies governing the internal      |
|       |     |     operation and management of the agency to which my |
|       |     |     assignment is made under this agreement will be    |
|       |     |     observed by me.                                    |
+-------+-----+--------------------------------------------------------+
| Yes   |     |                                                        |
| with  |     |                                                        |
| excep |     |                                                        |
| tions |     |                                                        |
|       |     |                                                        |
| att   |     |                                                        |
| ached |     |                                                        |
+-------+-----+--------------------------------------------------------+
|       | B.  |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |   h |                                                        |
|       | ave |                                                        |
|       |     |                                                        |
|       |   b |                                                        |
|       | een |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       | for |                                                        |
|       | med |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | hat |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | any |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | tra |                                                        |
|       | vel |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | and |                                                        |
|       |     |                                                        |
|       |  tr |                                                        |
|       | ans |                                                        |
|       | por |                                                        |
|       | tat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  ex |                                                        |
|       | pen |                                                        |
|       | ses |                                                        |
|       |     |                                                        |
|       |   c |                                                        |
|       | ove |                                                        |
|       | red |                                                        |
|       |     |                                                        |
|       |   f |                                                        |
|       | rom |                                                        |
|       |     |                                                        |
|       |   F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | age |                                                        |
|       | ncy |                                                        |
|       |     |                                                        |
|       |  ap |                                                        |
|       | pro |                                                        |
|       | pri |                                                        |
|       | ati |                                                        |
|       | ons |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | may |                                                        |
|       |     |                                                        |
|       |  be |                                                        |
|       |     |                                                        |
|       |  re |                                                        |
|       | cov |                                                        |
|       | era |                                                        |
|       | ble |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       |     |                                                        |
|       |   d |                                                        |
|       | ebt |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | due |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Uni |                                                        |
|       | ted |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Sta |                                                        |
|       | tes |                                                        |
|       |     |                                                        |
|       |  if |                                                        |
|       |     |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |  do |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | not |                                                        |
|       |     |                                                        |
|       |  se |                                                        |
|       | rve |                                                        |
|       |     |                                                        |
|       |  un |                                                        |
|       | til |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |   c |                                                        |
|       | omp |                                                        |
|       | let |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |   ( |                                                        |
|       | unl |                                                        |
|       | ess |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | erm |                                                        |
|       | ina |                                                        |
|       | ted |                                                        |
|       |     |                                                        |
|       |   e |                                                        |
|       | arl |                                                        |
|       | ier |                                                        |
|       |     |                                                        |
|       |  by |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | eit |                                                        |
|       | her |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | emp |                                                        |
|       | loy |                                                        |
|       | er) |                                                        |
|       |     |                                                        |
|       |  or |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | one |                                                        |
|       |     |                                                        |
|       |  ye |                                                        |
|       | ar, |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | whi |                                                        |
|       | che |                                                        |
|       | ver |                                                        |
|       |     |                                                        |
|       |  is |                                                        |
|       |     |                                                        |
|       |  sh |                                                        |
|       | ort |                                                        |
|       | er. |                                                        |
+-------+-----+--------------------------------------------------------+
|       | C.  |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |   h |                                                        |
|       | ave |                                                        |
|       |     |                                                        |
|       |   b |                                                        |
|       | een |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       | for |                                                        |
|       | med |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | hat |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | any |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | tra |                                                        |
|       | vel |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | and |                                                        |
|       |     |                                                        |
|       |  tr |                                                        |
|       | ans |                                                        |
|       | por |                                                        |
|       | tat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  ex |                                                        |
|       | pen |                                                        |
|       | ses |                                                        |
|       |     |                                                        |
|       |   c |                                                        |
|       | ove |                                                        |
|       | red |                                                        |
|       |     |                                                        |
|       |   f |                                                        |
|       | rom |                                                        |
|       |     |                                                        |
|       |   F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | age |                                                        |
|       | ncy |                                                        |
|       |     |                                                        |
|       |  ap |                                                        |
|       | pro |                                                        |
|       | pri |                                                        |
|       | ati |                                                        |
|       | ons |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | may |                                                        |
|       |     |                                                        |
|       |  be |                                                        |
|       |     |                                                        |
|       |  re |                                                        |
|       | cov |                                                        |
|       | era |                                                        |
|       | ble |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       |     |                                                        |
|       |   d |                                                        |
|       | ebt |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | due |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Uni |                                                        |
|       | ted |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Sta |                                                        |
|       | tes |                                                        |
|       |     |                                                        |
|       |  if |                                                        |
|       |     |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |  do |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | not |                                                        |
|       |     |                                                        |
|       |  se |                                                        |
|       | rve |                                                        |
|       |     |                                                        |
|       |  un |                                                        |
|       | til |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |   c |                                                        |
|       | omp |                                                        |
|       | let |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |   ( |                                                        |
|       | unl |                                                        |
|       | ess |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | erm |                                                        |
|       | ina |                                                        |
|       | ted |                                                        |
|       |     |                                                        |
|       |   e |                                                        |
|       | arl |                                                        |
|       | ier |                                                        |
|       |     |                                                        |
|       |  by |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | eit |                                                        |
|       | her |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | emp |                                                        |
|       | loy |                                                        |
|       | er) |                                                        |
|       |     |                                                        |
|       |  or |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | one |                                                        |
|       |     |                                                        |
|       |  ye |                                                        |
|       | ar, |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | whi |                                                        |
|       | che |                                                        |
|       | ver |                                                        |
|       |     |                                                        |
|       |  is |                                                        |
|       |     |                                                        |
|       |  sh |                                                        |
|       | ort |                                                        |
|       | er. |                                                        |
+-------+-----+--------------------------------------------------------+
|       | D.  |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |   h |                                                        |
|       | ave |                                                        |
|       |     |                                                        |
|       |   b |                                                        |
|       | een |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       | for |                                                        |
|       | med |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ppl |                                                        |
|       | ica |                                                        |
|       | ble |                                                        |
|       |     |                                                        |
|       |   p |                                                        |
|       | rov |                                                        |
|       | isi |                                                        |
|       | ons |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | sho |                                                        |
|       | uld |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |  po |                                                        |
|       | sit |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |   w |                                                        |
|       | ith |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | per |                                                        |
|       | man |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |  em |                                                        |
|       | plo |                                                        |
|       | yer |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | bec |                                                        |
|       | ome |                                                        |
|       |     |                                                        |
|       |   s |                                                        |
|       | ubj |                                                        |
|       | ect |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | red |                                                        |
|       | uct |                                                        |
|       | ion |                                                        |
|       | -in |                                                        |
|       | -fo |                                                        |
|       | rce |                                                        |
|       |     |                                                        |
|       |   p |                                                        |
|       | roc |                                                        |
|       | edu |                                                        |
|       | re. |                                                        |
+-------+-----+--------------------------------------------------------+
|       | E.  |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |  ag |                                                        |
|       | ree |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |  se |                                                        |
|       | rve |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |  Ci |                                                        |
|       | vil |                                                        |
|       |     |                                                        |
|       |   S |                                                        |
|       | erv |                                                        |
|       | ice |                                                        |
|       |     |                                                        |
|       |   u |                                                        |
|       | pon |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |   c |                                                        |
|       | omp |                                                        |
|       | let |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | for |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | per |                                                        |
|       | iod |                                                        |
|       |     |                                                        |
|       |  eq |                                                        |
|       | ual |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | hat |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       | sig |                                                        |
|       | nme |                                                        |
|       | nt. |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Sho |                                                        |
|       | uld |                                                        |
|       |     |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |   f |                                                        |
|       | ail |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |  se |                                                        |
|       | rve |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |  re |                                                        |
|       | qui |                                                        |
|       | red |                                                        |
|       |     |                                                        |
|       |  ti |                                                        |
|       | me, |                                                        |
|       |     |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |   h |                                                        |
|       | ave |                                                        |
|       |     |                                                        |
|       |   b |                                                        |
|       | een |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       | for |                                                        |
|       | med |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | hat |                                                        |
|       |     |                                                        |
|       |   I |                                                        |
|       |     |                                                        |
|       |   w |                                                        |
|       | ill |                                                        |
|       |     |                                                        |
|       |  be |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | lia |                                                        |
|       | ble |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Uni |                                                        |
|       | ted |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Sta |                                                        |
|       | tes |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | for |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | all |                                                        |
|       |     |                                                        |
|       |  ex |                                                        |
|       | pen |                                                        |
|       | ses |                                                        |
|       |     |                                                        |
|       |   ( |                                                        |
|       | exc |                                                        |
|       | ept |                                                        |
|       |     |                                                        |
|       |   s |                                                        |
|       | ala |                                                        |
|       | ry) |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  my |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       | sig |                                                        |
|       | nme |                                                        |
|       | nt. |                                                        |
|       |     |                                                        |
|       |  *( |                                                        |
|       | For |                                                        |
|       |     |                                                        |
|       |   F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | emp |                                                        |
|       | loy |                                                        |
|       | ees |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | onl |                                                        |
|       | y)* |                                                        |
+-------+-----+--------------------------------------------------------+
|       | F.  |                                                        |
|       |  Se |                                                        |
|       | cti |                                                        |
|       | ons |                                                        |
|       |     |                                                        |
|       |   C |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | and |                                                        |
|       |     |                                                        |
|       |   E |                                                        |
|       |     |                                                        |
|       |  (l |                                                        |
|       | eft |                                                        |
|       |     |                                                        |
|       |  bl |                                                        |
|       | ank |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | abo |                                                        |
|       | ve) |                                                        |
|       |     |                                                        |
|       |   h |                                                        |
|       | ave |                                                        |
|       |     |                                                        |
|       |   b |                                                        |
|       | een |                                                        |
|       |     |                                                        |
|       |   d |                                                        |
|       | ete |                                                        |
|       | rmi |                                                        |
|       | ned |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |  be |                                                        |
|       |     |                                                        |
|       |  no |                                                        |
|       | n-a |                                                        |
|       | ppl |                                                        |
|       | ica |                                                        |
|       | ble |                                                        |
|       |     |                                                        |
|       |  by |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | int |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  Co |                                                        |
|       | ngr |                                                        |
|       | ess |                                                        |
|       |     |                                                        |
|       |  un |                                                        |
|       | der |                                                        |
|       |     |                                                        |
|       |   P |                                                        |
|       | .L. |                                                        |
|       | 93- |                                                        |
|       | 638 |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | and |                                                        |
|       |     |                                                        |
|       |   P |                                                        |
|       | .L. |                                                        |
|       | 98- |                                                        |
|       | 146 |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | hat |                                                        |
|       |     |                                                        |
|       |   o |                                                        |
|       | bli |                                                        |
|       | gat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  em |                                                        |
|       | plo |                                                        |
|       | yee |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | ret |                                                        |
|       | urn |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |   F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |   G |                                                        |
|       | ove |                                                        |
|       | rnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |   e |                                                        |
|       | mpl |                                                        |
|       | oym |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | fol |                                                        |
|       | low |                                                        |
|       | ing |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | IPA |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |   d |                                                        |
|       | oes |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | not |                                                        |
|       |     |                                                        |
|       |  ap |                                                        |
|       | ply |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | HHS |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | emp |                                                        |
|       | loy |                                                        |
|       | ees |                                                        |
|       |     |                                                        |
|       |   s |                                                        |
|       | erv |                                                        |
|       | ing |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       | sig |                                                        |
|       | nme |                                                        |
|       | nts |                                                        |
|       |     |                                                        |
|       |   w |                                                        |
|       | ith |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Ind |                                                        |
|       | ian |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | tri |                                                        |
|       | bal |                                                        |
|       |     |                                                        |
|       |   o |                                                        |
|       | rga |                                                        |
|       | niz |                                                        |
|       | ati |                                                        |
|       | ons |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | imp |                                                        |
|       | lem |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | sel |                                                        |
|       | f-d |                                                        |
|       | ete |                                                        |
|       | rmi |                                                        |
|       | nat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |   o |                                                        |
|       | bje |                                                        |
|       | cti |                                                        |
|       | ves |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |  P. |                                                        |
|       | L.9 |                                                        |
|       | 3-6 |                                                        |
|       | 38. |                                                        |
+-------+-----+--------------------------------------------------------+
|       | G.  |                                                        |
|       |  As |                                                        |
|       | sig |                                                        |
|       | nee |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | (on |                                                        |
|       |     |                                                        |
|       |   R |                                                        |
|       | egu |                                                        |
|       | lar |                                                        |
|       |     |                                                        |
|       |   P |                                                        |
|       | urp |                                                        |
|       | ose |                                                        |
|       |     |                                                        |
|       |  As |                                                        |
|       | sig |                                                        |
|       | nme |                                                        |
|       | nt) |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | agr |                                                        |
|       | ees |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |  co |                                                        |
|       | mpl |                                                        |
|       | ete |                                                        |
|       |     |                                                        |
|       |   E |                                                        |
|       | xhi |                                                        |
|       | bit |                                                        |
|       |     |                                                        |
|       |   3 |                                                        |
|       | 34- |                                                        |
|       | 1-F |                                                        |
|       |     |                                                        |
|       |   ( |                                                        |
|       | Pos |                                                        |
|       | t-A |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |  Ev |                                                        |
|       | alu |                                                        |
|       | ati |                                                        |
|       | on) |                                                        |
|       |     |                                                        |
|       |  af |                                                        |
|       | ter |                                                        |
|       |     |                                                        |
|       |   c |                                                        |
|       | onc |                                                        |
|       | lus |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       | sig |                                                        |
|       | nme |                                                        |
|       | nt. |                                                        |
+-------+-----+--------------------------------------------------------+
|       | H.  |                                                        |
|       |   F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |  em |                                                        |
|       | plo |                                                        |
|       | yee |                                                        |
|       |     |                                                        |
|       |  on |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Ind |                                                        |
|       | ian |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | tri |                                                        |
|       | bal |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | org |                                                        |
|       | ani |                                                        |
|       | zat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | imp |                                                        |
|       | lem |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | sel |                                                        |
|       | f-d |                                                        |
|       | ete |                                                        |
|       | rmi |                                                        |
|       | nat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |   o |                                                        |
|       | bje |                                                        |
|       | cti |                                                        |
|       | ves |                                                        |
|       |     |                                                        |
|       |  of |                                                        |
|       |     |                                                        |
|       |   P |                                                        |
|       | .L. |                                                        |
|       | 93- |                                                        |
|       | 638 |                                                        |
|       |     |                                                        |
|       |  is |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | exe |                                                        |
|       | mpt |                                                        |
|       |     |                                                        |
|       |   f |                                                        |
|       | rom |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | RIF |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | dur |                                                        |
|       | ing |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       |     |                                                        |
|       |  pr |                                                        |
|       | ovi |                                                        |
|       | ded |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       |     |                                                        |
|       |   H |                                                        |
|       | HS- |                                                        |
|       | 351 |                                                        |
|       | -1- |                                                        |
|       | 70. |                                                        |
+-------+-----+--------------------------------------------------------+
|       | I.  |                                                        |
|       |   F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |  em |                                                        |
|       | plo |                                                        |
|       | yee |                                                        |
|       |     |                                                        |
|       |  on |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |  to |                                                        |
|       |     |                                                        |
|       |  no |                                                        |
|       | n-F |                                                        |
|       | ede |                                                        |
|       | ral |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | org |                                                        |
|       | ani |                                                        |
|       | zat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  ot |                                                        |
|       | her |                                                        |
|       |     |                                                        |
|       |   t |                                                        |
|       | han |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | Ind |                                                        |
|       | ian |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | tri |                                                        |
|       | bal |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | org |                                                        |
|       | ani |                                                        |
|       | zat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |  un |                                                        |
|       | der |                                                        |
|       | sta |                                                        |
|       | nds |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | any |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | org |                                                        |
|       | ani |                                                        |
|       | zat |                                                        |
|       | ion |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | RIF |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | dur |                                                        |
|       | ing |                                                        |
|       |     |                                                        |
|       |   a |                                                        |
|       | ssi |                                                        |
|       | gnm |                                                        |
|       | ent |                                                        |
|       |     |                                                        |
|       |   w |                                                        |
|       | ill |                                                        |
|       |     |                                                        |
|       |  ap |                                                        |
|       | ply |                                                        |
|       |     |                                                        |
|       |  in |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | the |                                                        |
|       |     |                                                        |
|       |   s |                                                        |
|       | ame |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | man |                                                        |
|       | ner |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       |     |                                                        |
|       |  if |                                                        |
|       |     |                                                        |
|       |  em |                                                        |
|       | plo |                                                        |
|       | yee |                                                        |
|       |     |                                                        |
|       |   w |                                                        |
|       | ere |                                                        |
|       |     |                                                        |
|       |     |                                                        |
|       | not |                                                        |
|       |     |                                                        |
|       |  on |                                                        |
|       |     |                                                        |
|       |  as |                                                        |
|       | sig |                                                        |
|       | nme |                                                        |
|       | nt. |                                                        |
+-------+-----+--------------------------------------------------------+
| > *   |     |                                                        |
| *PART |     |                                                        |
| >     |     |                                                        |
|  14 - |     |                                                        |
| > CER |     |                                                        |
| TIFIC |     |                                                        |
| ATION |     |                                                        |
| > OF  |     |                                                        |
| > ASS |     |                                                        |
| IGNED |     |                                                        |
| >     |     |                                                        |
| EMPLO |     |                                                        |
| YEE** |     |                                                        |
+-------+-----+--------------------------------------------------------+
| >     |     |                                                        |
|  35\. |     |                                                        |
| > In  |     |                                                        |
| > si  |     |                                                        |
| gning |     |                                                        |
| >     |     |                                                        |
|  this |     |                                                        |
| >     |     |                                                        |
| agree |     |                                                        |
| ment, |     |                                                        |
| > I   |     |                                                        |
| > ce  |     |                                                        |
| rtify |     |                                                        |
| >     |     |                                                        |
|  that |     |                                                        |
| > I   |     |                                                        |
| >     |     |                                                        |
| under |     |                                                        |
| stand |     |                                                        |
| > the |     |                                                        |
| >     |     |                                                        |
| terms |     |                                                        |
| > of  |     |                                                        |
| >     |     |                                                        |
|  this |     |                                                        |
| >     |     |                                                        |
|  agre |     |                                                        |
| ement |     |                                                        |
| > and |     |                                                        |
| >     |     |                                                        |
| agree |     |                                                        |
| > to  |     |                                                        |
| > the |     |                                                        |
| > r   |     |                                                        |
| ules, |     |                                                        |
| > r   |     |                                                        |
| egula |     |                                                        |
| tions |     |                                                        |
| > and |     |                                                        |
| > pol |     |                                                        |
| icies |     |                                                        |
| > a   |     |                                                        |
| pplic |     |                                                        |
| able. |     |                                                        |
| >     |     |                                                        |
| > [/  |     |                                                        |
| >     |     |                                                        |
|  /]{. |     |                                                        |
| under |     |                                                        |
| line} |     |                                                        |
| >     |     |                                                        |
| >     |     |                                                        |
|  Sign |     |                                                        |
| ature |     |                                                        |
| > of  |     |                                                        |
| > Ass |     |                                                        |
| ignee |     |                                                        |
| >     |     |                                                        |
|  Date |     |                                                        |
+-------+-----+--------------------------------------------------------+
| > *   |     |                                                        |
| *PART |     |                                                        |
| > 15- |     |                                                        |
| > CER |     |                                                        |
| TIFIC |     |                                                        |
| ATION |     |                                                        |
| > OF  |     |                                                        |
| >     |     |                                                        |
|  APPR |     |                                                        |
| OVING |     |                                                        |
| > O   |     |                                                        |
| FFICI |     |                                                        |
| ALS** |     |                                                        |
+-------+-----+--------------------------------------------------------+
| >     |     |                                                        |
|  36\. |     |                                                        |
| > Fe  |     |                                                        |
| deral |     |                                                        |
| > Sup |     |                                                        |
| ervis |     |                                                        |
| or\'s |     |                                                        |
| >     |     |                                                        |
| Commi |     |                                                        |
| tment |     |                                                        |
| >     |     |                                                        |
|  (for |     |                                                        |
| > re  |     |                                                        |
| gular |     |                                                        |
| > pu  |     |                                                        |
| rpose |     |                                                        |
| > a   |     |                                                        |
| ssign |     |                                                        |
| ments |     |                                                        |
| >     |     |                                                        |
| only) |     |                                                        |
| >     |     |                                                        |
| > In  |     |                                                        |
| > si  |     |                                                        |
| gning |     |                                                        |
| >     |     |                                                        |
|  this |     |                                                        |
| >     |     |                                                        |
| agree |     |                                                        |
| ment, |     |                                                        |
| > I   |     |                                                        |
| > ce  |     |                                                        |
| rtify |     |                                                        |
| >     |     |                                                        |
|  that |     |                                                        |
| > I   |     |                                                        |
| >     |     |                                                        |
| under |     |                                                        |
| stand |     |                                                        |
| > and |     |                                                        |
| >     |     |                                                        |
|  will |     |                                                        |
| > c   |     |                                                        |
| omply |     |                                                        |
| >     |     |                                                        |
|  with |     |                                                        |
| > the |     |                                                        |
| > re  |     |                                                        |
| quire |     |                                                        |
| ments |     |                                                        |
| >     |     |                                                        |
|  upon |     |                                                        |
| > Fe  |     |                                                        |
| deral |     |                                                        |
| > s   |     |                                                        |
| uperv |     |                                                        |
| isors |     |                                                        |
| >     |     |                                                        |
|  both |     |                                                        |
| > d   |     |                                                        |
| uring |     |                                                        |
| > the |     |                                                        |
| >     |     |                                                        |
| assig |     |                                                        |
| nment |     |                                                        |
| > p   |     |                                                        |
| eriod |     |                                                        |
| > and |     |                                                        |
| > d   |     |                                                        |
| uring |     |                                                        |
| > the |     |                                                        |
| >     |     |                                                        |
| post- |     |                                                        |
| assig |     |                                                        |
| nment |     |                                                        |
| >     |     |                                                        |
| evalu |     |                                                        |
| ation |     |                                                        |
| > p   |     |                                                        |
| eriod |     |                                                        |
| >     |     |                                                        |
| which |     |                                                        |
| >     |     |                                                        |
|  will |     |                                                        |
| > fo  |     |                                                        |
| llow. |     |                                                        |
| >     |     |                                                        |
| > [/  |     |                                                        |
| >     |     |                                                        |
|  /]{. |     |                                                        |
| under |     |                                                        |
| line} |     |                                                        |
| >     |     |                                                        |
| >     |     |                                                        |
|  Sign |     |                                                        |
| ature |     |                                                        |
| > of  |     |                                                        |
| > Fe  |     |                                                        |
| deral |     |                                                        |
| >     |     |                                                        |
| Super |     |                                                        |
| visor |     |                                                        |
| >     |     |                                                        |
|  Date |     |                                                        |
+-------+-----+--------------------------------------------------------+

HHS Modifications to OPM\'s Optional Form (OF) 69 Page 8

+----------------------------------+-----------------------------------+
| > 37\. Certification of          |                                   |
| > Recommending Operating         |                                   |
| > Division Official              |                                   |
|                                  |                                   |
| The Operating Division endorses  |                                   |
| all terms provided in this       |                                   |
| agreement. (If a non-Federal     |                                   |
| employee on leave without pay is |                                   |
| being appointed to a Federal     |                                   |
| position, I certify that the     |                                   |
| assignee\'s skills are not       |                                   |
| available among present          |                                   |
| employees of the Operating       |                                   |
| Division or among former         |                                   |
| employees on a Reemployment      |                                   |
| Priority List for the commuting  |                                   |
| area of the assignment.          |                                   |
|                                  |                                   |
| > [/ /]{.underline}              |                                   |
|                                  |                                   |
| Signature of Operating Division  |                                   |
| Endorsing Official Date          |                                   |
|                                  |                                   |
| > 38\. Title:                    |                                   |
+----------------------------------+-----------------------------------+
| > 39\. Certification of          | > 40\. Certification of           |
| > Authorizing Non-Federal        | > Authorizing Federal Official    |
| > Official                       |                                   |
+----------------------------------+-----------------------------------+
| > In signing this agreement we   |                                   |
| > certify that the description   |                                   |
| > of duties is current and fully |                                   |
| > and accurately describes those |                                   |
| > of the assigned employee, that |                                   |
| > this assignment is being       |                                   |
| > entered into (or extended) for |                                   |
| > a sound, mutually beneficial,  |                                   |
| > public purpose and not solely  |                                   |
| > for the employee\'s benefit,   |                                   |
| > and that at the completion of  |                                   |
| > the assignment, the            |                                   |
| > participating employee will be |                                   |
| > returned to the position       |                                   |
| > occupied at the time this      |                                   |
| > agreement was entered into or  |                                   |
| > a position of like seniority,  |                                   |
| > status, and pay unless the     |                                   |
| > employee must be subject to    |                                   |
| > reduction-in-force (RIF)       |                                   |
| > procedures:                    |                                   |
+----------------------------------+-----------------------------------+
| > Signature of Authorizing       | > Signature of Authorizing        |
| > Non-Federal Official           | > Federal Official                |
+----------------------------------+-----------------------------------+
| > 41\. Date of Signature:        | > 42\. Date of Signature:         |
+----------------------------------+-----------------------------------+
| > 43\. Typed or Printed Name and | > 44\. Typed or Printed Name and  |
| > Title                          | > Title                           |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
| > 45\. Signature of ADDITIONAL   |                                   |
| > APPROVING OFFICIAL: required   |                                   |
| > not required                   |                                   |
+----------------------------------+-----------------------------------+
| > [/ /]{.underline}              |                                   |
| >                                |                                   |
| > Signature Date                 |                                   |
+----------------------------------+-----------------------------------+
| > Typed or Printed Name and      |                                   |
| > Title                          |                                   |
+----------------------------------+-----------------------------------+
| > **Privacy Act Statement**      |                                   |
| >                                |                                   |
| > **Sections 3373 and 3374,      |                                   |
| > Assignment of Employees To or  |                                   |
| > From State or Local            |                                   |
| > Governments, of Title 5, U.S.  |                                   |
| > Code, authorizes collection of |                                   |
| > this information. The data     |                                   |
| > will be used primarily to      |                                   |
| > formally document and record   |                                   |
| > your temporary assignment to   |                                   |
| > or from a State or local       |                                   |
| > government, institution of     |                                   |
| > higher education, Indian       |                                   |
| > tribal government, or other    |                                   |
| > eligible organization. This    |                                   |
| > information may also be used   |                                   |
| > as the legal basis for         |                                   |
| > personnel and financial        |                                   |
| > transactions, to identify you  |                                   |
| > when requesting information    |                                   |
| > about you, e.g., from prior    |                                   |
| > employers, educational         |                                   |
| > institutions, or law           |                                   |
| > enforcement agencies, or by    |                                   |
| > State, Local, or Federal       |                                   |
| > income taxing agencies.**      |                                   |
| >                                |                                   |
| > **Solicitation of your Social  |                                   |
| > Security Number (SSN) is       |                                   |
| > authorized by Executive Order  |                                   |
| > 9397, which permitted use of   |                                   |
| > the SSN as an identifier of    |                                   |
| > individual records maintained  |                                   |
| > by Federal agencies.           |                                   |
| > Furnishing your SSN or any     |                                   |
| > other data requested is        |                                   |
| > voluntary. However, failure to |                                   |
| > provide any of the requested   |                                   |
| > information may result in your |                                   |
| > being ineligible for           |                                   |
| > participation in the           |                                   |
| > Intergovernmental Assignment   |                                   |
| > Program.**                     |                                   |
+----------------------------------+-----------------------------------+

> HHS Modifications to OPM\'s Optional Form (OF) 69 Page 10
>
> Assignment Agreement
>
> Title IV of the Intergovernmental Personnel Act of 1970
>
> (5 U.S.C. 3371 - 3376)
>
> Certification:
>
> I endorse all terms provided in this agreement. I certify that this
> assignee\'s skills are not available among present employees of the
> ICD or among former employees on the Reemployment Priority List and
> that this agreement is being entered into for a sound, mutually
> beneficial, public purpose and not solely for the employee\'s benefit.
>
> Signature of Human Resources Officer Date
>
> Certification of the Office of Human Resources, NIH:
>
> In signing this agreement, I certify that I have reviewed this
> agreement and find that it meets all legal and regulatory policies and
> procedures governing the IPA mobility program.
>
> Director of Human Resources Date