**NCI-FREDERICK CLEARANCE OF PERSONNEL FOR SEPARATION OR TRANSFER**

Employees Name/Title:      

Organization, Building, Room:      

Forwarding Address:      

Date of Departure:      

+-------------------+---------------+----+----------------------------+
| ###               |               |    |                            |
| #### NOTE TO EMPL |               |    |                            |
| OYEE: You must si |               |    |                            |
| gn the statement  |               |    |                            |
| below and visit e |               |    |                            |
| ach office listed |               |    |                            |
|  to acquire a cle |               |    |                            |
| arance signature. |               |    |                            |
|  All offices must |               |    |                            |
|  be visited and y |               |    |                            |
| our laboratory ad |               |    |                            |
| ministrative staf |               |    |                            |
| f must be the las |               |    |                            |
| t stop[,]{.underl |               |    |                            |
| ine} where you wi |               |    |                            |
| ll turn-in the to |               |    |                            |
| p portion of this |               |    |                            |
|  form completed.  |               |    |                            |
| Your laboratory a |               |    |                            |
| dministrative sta |               |    |                            |
| ff will return co |               |    |                            |
| mpleted form to t |               |    |                            |
| he Administrative |               |    |                            |
|  Resource Center. |               |    |                            |
+-------------------+---------------+----+----------------------------+
| To the best of my |               |    |                            |
| knowledge, I have |               |    |                            |
| no NIH Property,  |               |    |                            |
| records, or       |               |    |                            |
| correspondence    |               |    |                            |
| and I do not have |               |    |                            |
| any unresolved    |               |    |                            |
| indebtedness with |               |    |                            |
| the Department.   |               |    |                            |
|                   |               |    |                            |
| [\_\_\_           |               |    |                            |
| \_\_\_\_\_\_\_\_\ |               |    |                            |
| _\_\_\_\_\_\_\_\_ |               |    |                            |
| \_\_\_\_\_\_\_\_\ |               |    |                            |
| _\_\_\_\_\_\_\_\_ |               |    |                            |
| \_                |               |    |                            |
| \_\_\_\_\_\_\_\_\ |               |    |                            |
| _\_\_\_\_]{.mark} |               |    |                            |
|                   |               |    |                            |
| ##### Employ      |               |    |                            |
| ee Signature Date |               |    |                            |
+-------------------+---------------+----+----------------------------+
| **Please see:**   | **Clearance   |    | ####### Signature          |
|                   | Action        |    |                            |
|                   | Item:**       |    |                            |
+-------------------+---------------+----+----------------------------+
| FT. DETRICK VEH.  | Turn-In Ft.   |    |                            |
| REG. OFFICE       | Detrick Decal |    |                            |
|                   |               |    |                            |
| Bldg. 1500        |               |    |                            |
+-------------------+---------------+----+----------------------------+
| ENVIRONMENT,      | Turn-In       |    |                            |
| HEALTH, AND       | Radiation     |    |                            |
| SAFETY            | Badge(s)      |    |                            |
|                   |               |    |                            |
| Bldg. 426/118,    |               |    |                            |
| x1451             |               |    |                            |
+-------------------+---------------+----+----------------------------+
|                   | Submit Final  |    |                            |
|                   | Bioassay(s)   |    |                            |
+-------------------+---------------+----+----------------------------+
|                   | Delete        |    |                            |
|                   | Pathogen      |    |                            |
|                   | Registration  |    |                            |
|                   | \#            |    |                            |
+-------------------+---------------+----+----------------------------+
| OCCUPATIONAL      | Final Serum   |    |                            |
| HEALTH            | Save          |    |                            |
|                   |               |    |                            |
| Bldg. 426, x1096  |               |    |                            |
+-------------------+---------------+----+----------------------------+
|                   | Medical       |    |                            |
|                   | Surveillance  |    |                            |
|                   | Programs      |    |                            |
+-------------------+---------------+----+----------------------------+
| PROTECTIVE        | Turn-In NIH   |    |                            |
| SERVICES          | and/or        |    |                            |
|                   | NCI-Frederick |    |                            |
| Bldg. 426, x1091  | I.D.,         |    |                            |
|                   | CardKey, Room |    |                            |
|                   | Keys          |    |                            |
+-------------------+---------------+----+----------------------------+
|                   | Controlled    |    |                            |
|                   | Substance Log |    |                            |
|                   | Notification  |    |                            |
+-------------------+---------------+----+----------------------------+
|                   | Tier 1        |    |                            |
|                   | Criti         |    |                            |
|                   | cal/Essential |    |                            |
|                   | Employee      |    |                            |
+-------------------+---------------+----+----------------------------+
| YOUR SUPERVISOR   | All lab books |    |                            |
|                   | and data      |    |                            |
|                   | returned.     |    |                            |
|                   | Work area     |    |                            |
|                   | cleaned.      |    |                            |
+-------------------+---------------+----+----------------------------+
| YOUR LABORATORY   | A             |    |                            |
| ADMINISTRATIVE    | dministrative |    |                            |
| STAFF             | Staff         |    |                            |
|                   | Completes the |    |                            |
|                   | Appropriate   |    |                            |
|                   | Checklist     |    |                            |
|                   | Below         |    |                            |
+-------------------+---------------+----+----------------------------+
| ######            |               |    |                            |
|  Lab Secretary or |               |    |                            |
|  Administrative L |               |    |                            |
| ab Manager Must C |               |    |                            |
| omplete the Check |               |    |                            |
| list Below (All i |               |    |                            |
| tems must be revi |               |    |                            |
| ewed and checked) |               |    |                            |
+-------------------+---------------+----+----------------------------+
| Delete from       |               |    |                            |
| Radiological      |               | De |                            |
| Program \#        |               | le |                            |
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+-------------------+---------------+----+----------------------------+
| Property          |               |    |                            |
| Clearance (send   |               | L  |                            |
| email             |               | ib |                            |
| notification to   |               | ra |                            |
| both Steve Koogle |               | ry |                            |
| <sko              |               | C  |                            |
| ogle@ncifcrf.gov> |               | le |                            |
| and Kurt          |               | ar |                            |
| Zimmerman         |               | an |                            |
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| ank@ncifcrf.gov>) |               | (  |                            |
| 1 WEEK NOTICE     |               | se |                            |
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+-------------------+---------------+----+----------------------------+
| Laser Safety      |               |    |                            |
| Program: Send     |               | E  |                            |
| email             |               | ma |                            |
| notification to   |               | il |                            |
| <rso@ncifcrf.gov> |               | A  |                            |
| for all employees |               | cc |                            |
| who received a    |               | ou |                            |
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| Include name and  |               | an |                            |
| departure date. 2 |               | ce |                            |
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| REQUIRED.         |               | ed |                            |
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+-------------------+---------------+----+----------------------------+
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+-------------------+---------------+----+----------------------------+
| Property Control  |               |    |                            |
| Officer           |               | US |                            |
| Responsibility    |               | Ba |                            |
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+-------------------+---------------+----+----------------------------+
| I.M.P.A.C.        |               |    |                            |
| Purchase Cards    |               | N  |                            |
| Cut Up and ARC    |               | IH |                            |
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+-------------------+---------------+----+----------------------------+
| Dom/Intl Calling  |               |    |                            |
| Card(s) Returned  |               | To |                            |
| to ARC            |               | ol |                            |
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+-------------------+---------------+----+----------------------------+
| Resolution of     |               |    |                            |
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+-------------------+---------------+----+----------------------------+
| Super Computer    |               | N  |                            |
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+-------------------+---------------+----+----------------------------+
| ITAS System       |               |    |                            |
| (recording        |               | A  |                            |
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+-------------------+---------------+----+----------------------------+
| EPMP Closeout --  |               |    |                            |
| forward to ARC    |               | Ce |                            |
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|                   |               | wz |                            |
|                   |               | im |                            |
|                   |               | me |                            |
|                   |               | rm |                            |
|                   |               | an |                            |
|                   |               | @m |                            |
|                   |               | ai |                            |
|                   |               | l. |                            |
|                   |               | nc |                            |
|                   |               | if |                            |
|                   |               | cr |                            |
|                   |               | f. |                            |
|                   |               | go |                            |
|                   |               | v> |                            |
+-------------------+---------------+----+----------------------------+
| ###### Admin      |               |    |                            |
| istrative Resourc |               |    |                            |
| e Center Use Only |               |    |                            |
+-------------------+---------------+----+----------------------------+
| SAIC I.M.P.A.C.   |               |    |                            |
| Purchase Card     |               | Go |                            |
| Returned          |               | ve |                            |
|                   |               | rn |                            |
|                   |               | me |                            |
|                   |               | nt |                            |
|                   |               | I. |                            |
|                   |               | M. |                            |
|                   |               | P. |                            |
|                   |               | A. |                            |
|                   |               | C. |                            |
|                   |               | Pu |                            |
|                   |               | rc |                            |
|                   |               | ha |                            |
|                   |               | se |                            |
|                   |               | Ca |                            |
|                   |               | rd |                            |
|                   |               | Re |                            |
|                   |               | tu |                            |
|                   |               | rn |                            |
|                   |               | ed |                            |
+-------------------+---------------+----+----------------------------+
|                   |               |    |                            |
| Domes             |               | U. |                            |
| tic/International |               | S. |                            |
| Calling Card(s)   |               | Ba |                            |
| Returned          |               | nk |                            |
|                   |               | Tr |                            |
|                   |               | av |                            |
|                   |               | el |                            |
|                   |               | Ca |                            |
|                   |               | rd |                            |
|                   |               | Re |                            |
|                   |               | tu |                            |
|                   |               | rn |                            |
|                   |               | ed |                            |
+-------------------+---------------+----+----------------------------+
| TFS Departure     |               |    |                            |
| Date              |               | NE |                            |
|                   |               | Ds |                            |
|                   |               | D  |                            |
|                   |               | ep |                            |
|                   |               | ar |                            |
|                   |               | tu |                            |
|                   |               | re |                            |
|                   |               | Da |                            |
|                   |               | te |                            |
+-------------------+---------------+----+----------------------------+
| CYBORG Departure  |               |    |                            |
| Date              |               | Mo |                            |
|                   |               | di |                            |
|                   |               | fy |                            |
|                   |               | FY |                            |
|                   |               | Bu |                            |
|                   |               | dg |                            |
|                   |               | et |                            |
|                   |               | Sh |                            |
|                   |               | ee |                            |
|                   |               | ts |                            |
|                   |               | (  |                            |
|                   |               | BM |                            |
|                   |               | S) |                            |
+-------------------+---------------+----+----------------------------+
| Comp. Systems     |               |    |                            |
| Access            |               | Cl |                            |
| Deactivated (TFS, |               | os |                            |
| Smartstream, ADB) |               | eo |                            |
|                   |               | ut |                            |
|                   |               | EP |                            |
|                   |               | MP |                            |
+-------------------+---------------+----+----------------------------+
| Provide copy of   |               |    |                            |
| clearance form to |               |    |                            |
| travel core       |               |    |                            |
| representative    |               |    |                            |
+-------------------+---------------+----+----------------------------+

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Administrative Officer Signature/Date 8/1/07