**Addendum to Declaration for Federal Employment (OF 306)**

**Indian Health Service**

**Child Care & Indian Child Care Worker Positions**

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**Item 15a. Agency Specific Questions**

**Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Social
Security Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**(Please print)**

**Job Title in Announcement: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Announcement Number: \_\_\_\_\_\_\_\_\_\_\_**

Section 231 of the Crime Control Act 1990, Public Law 101-647, requires
that employment applications for Federal child care positions contain a
question asking whether the individual has ever been arrested for or
charged with a crime involving a child and for the disposition of the
arrest or charge.

Section 408 of the Miscellaneous Indian Legislation, Public Law 101-630,
contains a related requirement for positions in the Department of Health
and Human Services that involve regular contact with or control over
Indian children. The agency must ensure that persons hired for these
positions have not been found guilty of or pleaded nolo contendere or
guilty to certain crimes.

To assure compliance with the above laws, the following questions are
added to the Declaration for Federal Employment:

1)  Have you ever been arrested for or charged with a crime involving a
    child? *YES\_\_\_\_\_ NO\_\_\_\_\_\_*

> *\[If A**YES**@, provide the date, explanation of the violation,
> disposition of the arrest or charge, place of*
>
> *occurrence, and the name and address of the police department or
> court involved.\]*

2)  Have you ever been found guilty of, or entered a plea of nolo
    contendere (no contest) or guilty to, any felonious or misdemeanor
    offense under Federal, State, or tribal law involving crimes of
    violence; sexual assault, molestation, exploitation, contact or
    prostitution; or crimes against persons; or offenses committed
    against children? *YES\_\_\_\_\_\_ NO\_\_\_\_\_\_*

> *\[If A**YES**@, provide the date, explanation of the violation,
> disposition of the arrest or charge, place of occurrence, and the name
> address of the police department or court involved.\]*

I certify that (1) my response to these questions is made under penalty
of perjury, which is punishable by fines of up to \$2,000 or 5 years
imprisonment, or both; and (2) I have received notice that a criminal
check will be conducted. I understand my right to obtain a copy of any
criminal history report made available to the Indian Health Service and
my right to challenge the accuracy and completeness of any information
contained in the report.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_**

**Applicant=s Signature (sign in ink) Date**

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  Public Burden Statement: In accordance with Paperwork Reduction Act (5
  CFR 1320.8 (b)(3), a Federal agency may not conduct or sponsor, and a
  person is not required to respond to, a collection of information
  unless it displays a currently valid OMB control number. Respondents
  must be informed (on the reporting instrument, in instructions, or in a
  cover letter) the reasons for which the information will be collected;
  the way the information will be used to further the proper performance
  of the functions of the agency; whether responses to the collection of
  the information are voluntary, required to obtain a benefit (citing
  authority), or mandatory (citing authority); and the nature and extent
  of confidentiality to be provided, if any (citing authority). Public
  reporting burden for this collection of information is estimated to
  average 15 minutes per response, including time for reviewing
  instructions, searching existing data sources, gathering and
  maintaining the necessary data, and completing and reviewing the
  collection information. Send comments regarding the burden estimate or
  any other aspect of this collection of information to the IHS PRA
  Information Collection Clearance Staff, 12300 Twinbrook Parkway, Suite
  450, Rockville, MD 20852. ***Please do not send completed data
  collection instruments to this address.***

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FORM APPROVED: O.M.B. NO. 0917-0028 Expires 02/28/2009