+------------------------------------------+-----+---------------------+
| **DEPARTMENT OF HEALTH AND HUMAN         | N   |                     |
| SERVICES**                               | AME |                     |
|                                          | OF  |                     |
| FOOD AND DRUG ADMINISTRATION             | EM  |                     |
|                                          | PLO |                     |
| **CERTIFICATION FOR SEPARATING           | YEE |                     |
| EMPLOYEES**                              | *(T |                     |
|                                          | ype |                     |
|                                          | or  |                     |
|                                          | P   |                     |
|                                          | rin |                     |
|                                          | *t) |                     |
+------------------------------------------+-----+---------------------+
|                                          |     |                     |
|                                          |     |                     |
+------------------------------------------+-----+---------------------+
|                                          | ORG |                     |
|                                          | ANI |                     |
|                                          | ZAT |                     |
|                                          | ION |                     |
+------------------------------------------+-----+---------------------+
|                                          |     |                     |
|                                          |     |                     |
+------------------------------------------+-----+---------------------+
| This form is completed by officers and   |     |                     |
| employees associated with carrying out   |     |                     |
| FDA Programs as follows: FDA regular     |     |                     |
| employees, PHS\                          |     |                     |
| Commissioned Corps personnel, and        |     |                     |
| Federal assignees under the              |     |                     |
| Intergovernmental Personnel Act of 1970. |     |                     |
|                                          |     |                     |
| Your attention is directed to certain    |     |                     |
| statutory prohibitions for employees who |     |                     |
| leave the employment of the U.S.         |     |                     |
| Government. These portions are           |     |                     |
| summarized below.                        |     |                     |
|                                          |     |                     |
| A. Post employment restrictions, 18      |     |                     |
| U.S.C. 207, stipulates that after having |     |                     |
| been employed by the United States:      |     |                     |
|                                          |     |                     |
| 1\. 207 (a)(1). At any time after        |     |                     |
| employment has ceased, a former          |     |                     |
| Government employee shall not knowingly  |     |                     |
| make any communication to\               |     |                     |
| or appearance before, with the intent to |     |                     |
| influence, any officer or employee of    |     |                     |
| any department, agency, court of the     |     |                     |
| United\                                  |     |                     |
| States or the District of Columbia, in   |     |                     |
| connection with a particular matter      |     |                     |
| involving a specific party or specific   |     |                     |
| parties in\                              |     |                     |
| which the United States is a party or    |     |                     |
| has a direct or substantial interest,    |     |                     |
| and in which while employed, the former\ |     |                     |
| Government employee participated         |     |                     |
| personally and substantially.            |     |                     |
|                                          |     |                     |
| 2\. 207 (a)(2). Within two years after   |     |                     |
| employment has ceased, a former          |     |                     |
| Government employee shall not knowingly  |     |                     |
| make, with the intent to influence,      |     |                     |
| communication to or appearance before    |     |                     |
| any officer or employee of the United    |     |                     |
| States Government on behalf of any\      |     |                     |
| other person in any matter in which the  |     |                     |
| United States is a party to or has a     |     |                     |
| direct and substantial interest, which   |     |                     |
| matter was pending under the former      |     |                     |
| employee's official responsibility       |     |                     |
| during the last year of Government       |     |                     |
| employment and which\                    |     |                     |
| involved specific parties at the time it |     |                     |
| was pending.                             |     |                     |
|                                          |     |                     |
| > 3\. 207 (b). Any former employee of    |     |                     |
| > the Government who personally and      |     |                     |
| > substantially participated in ongoing  |     |                     |
| > trade or treaty negotiation\           |     |                     |
| > on behalf of the United States within  |     |                     |
| > the one-year period preceding his or   |     |                     |
| > her termination from Government        |     |                     |
| > service, and had access to information |     |                     |
| > concerning the trade or treaty         |     |                     |
| > negotiation which is exempt from       |     |                     |
| > disclosure under section 552 of Title\ |     |                     |
| > 5, shall not on the basis of that      |     |                     |
| > information, knowingly represent, aid  |     |                     |
| > or advise any other person except the  |     |                     |
| > United States concerning such ongoing  |     |                     |
| > negotiations for a period of one year  |     |                     |
| > after his or her employment with the   |     |                     |
| > United States ended.                   |     |                     |
| >                                        |     |                     |
| > 4\. 207 (c). Within one year after     |     |                     |
| > employment has ceased, Senate          |     |                     |
| > confirmed Presidential appointees      |     |                     |
| > employed at a rate of pay specified\   |     |                     |
| > on the Executive Schedule (Ex) levels  |     |                     |
| > II through V, employees whose rate of  |     |                     |
| > basic pay is equal to or greater than  |     |                     |
| > the rate of\                           |     |                     |
| > basic pay for level V of the Executive |     |                     |
| > Schedule and officers in the           |     |                     |
| > Commissioned Corps assigned to pay     |     |                     |
| > grades of 07 or\                       |     |                     |
| > above, are restricted from knowingly   |     |                     |
| > making, with the intent to influence,  |     |                     |
| > any communication or appearance before |     |                     |
| > FDA\                                   |     |                     |
| > on behalf of any other person, in      |     |                     |
| > connection with any matter on which    |     |                     |
| > the person seeks official action by    |     |                     |
| > FDA.                                   |     |                     |
|                                          |     |                     |
| 5\. 207 (f). For a period of one year    |     |                     |
| after Government employment has ceased,  |     |                     |
| any former employee who was employed at  |     |                     |
| the pay\                                 |     |                     |
| levels described in 207(c) may not       |     |                     |
| represent, aid or advise a foreign       |     |                     |
| entity with the intent to influence a    |     |                     |
| decision of any\                         |     |                     |
| officer or employee of any Department or |     |                     |
| Agency of the United States, in carrying |     |                     |
| out his or her official duties.          |     |                     |
|                                          |     |                     |
| > B. 21 U.S.C. 331 (j) prohibits:        |     |                     |
| >                                        |     |                     |
| > The using by any person to his/her own |     |                     |
| > advantage, or revealing, other than to |     |                     |
| > the Secretary or officers or employees |     |                     |
| > of the Department, or\                 |     |                     |
| > to the courts when relevant in any     |     |                     |
| > judicial proceeding under this         |     |                     |
| > chapter, any information acquired      |     |                     |
| > under authority of section 344, 348,   |     |                     |
| > 350a, 355 360, 360b, 360c, 360d, 360e, |     |                     |
| > 360f, 360h, 360i, 360j, 374, 379, or   |     |                     |
| > 379e, of this title concerning any     |     |                     |
| > method or process which as a trade     |     |                     |
| > secret is entitled to protection.      |     |                     |
| >                                        |     |                     |
| > C. 42 U.S.C. 423 (f), the Procurement  |     |                     |
| > Integrity Act, prohibits:              |     |                     |
| >                                        |     |                     |
| > An employee who was a procurement      |     |                     |
| > official with respect to a particular  |     |                     |
| > procurement from (1) participating on  |     |                     |
| > behalf of a competing\                 |     |                     |
| > contractor in any negotiations leading |     |                     |
| > to the award, modification, or         |     |                     |
| > extension of a contract for such       |     |                     |
| > procurement, or (2) participating\     |     |                     |
| > personally and substantially on behalf |     |                     |
| > of the competing contractor in the     |     |                     |
| > performance of such contract, for a    |     |                     |
| > period of two years after the\         |     |                     |
| > date of the employee's last personal   |     |                     |
| > and substantial participation in the   |     |                     |
| > procurement on behalf of the           |     |                     |
| > Government.                            |     |                     |
| >                                        |     |                     |
| > D. Section 3(d) of the Federal         |     |                     |
| > Workforce Restructuring Act of 1994    |     |                     |
| > provides that any former employee who  |     |                     |
| > accepted a buyout under the Act\       |     |                     |
| > and then accepts                       |     |                     |
| > employment\--including employment      |     |                     |
| > under a personal services              |     |                     |
| > contract\--with the Government within  |     |                     |
| > five years of the date\                |     |                     |
| > of separation, shall be required to    |     |                     |
| > repay the entire amount of the buyout. |     |                     |
| >                                        |     |                     |
| > Under certain circumstances, employees |     |                     |
| > may be eligible for exceptions or      |     |                     |
| > waivers with respect to some of the    |     |                     |
| > above statutory prohibitions.          |     |                     |
+------------------------------------------+-----+---------------------+
| CERTIFICATION                            |     |                     |
|                                          |     |                     |
| I certify that:                          |     |                     |
|                                          |     |                     |
| > 1\. I have received a copy of Title 18 |     |                     |
| > U.S.C. 207 \"Restrictions on Former    |     |                     |
| > Officers, Employees, and Elected       |     |                     |
| > Officials of the\                      |     |                     |
| > Executive and Legislative Branches;\"  |     |                     |
| > and                                    |     |                     |
| >                                        |     |                     |
| > 2\. I understand that I am personally  |     |                     |
| > responsible for complying with all     |     |                     |
| > Federal conflict of interest statutes  |     |                     |
| > including those\                       |     |                     |
| > restrictions on post-employment        |     |                     |
| > activities cited above.                |     |                     |
+------------------------------------------+-----+---------------------+
| SIGNATURE                                |     | DATE                |
+------------------------------------------+-----+---------------------+
|                                          |     |                     |
+------------------------------------------+-----+---------------------+