Fillable Phs-1122-1 FORM PHS 1122-1

Fill Online, Printable, Fillable, Blank Phs-1122-1 FORM PHS 1122-1 Form

Use Fill to complete blank online HEALTH AND HUMAN SERVICES (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Phs-1122-1 FORM PHS 1122-1

On average this form takes 51 minutes to complete

The Phs-1122-1 FORM PHS 1122-1 form is 4 pages long and contains:

  • 6 signatures
  • 32 check-boxes
  • 165 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Health and Human Services

BROWSE HEALTH AND HUMAN SERVICES (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
APPLICATION FOR TRAINING FOR PHS COMMISSIONED PERSONNEL
SECTION I - TO BE COMPLETED BY ALL APPLICANTS
INSTRUCTIONS: Before completing the application, read all the items carefully including the definitions of long-term training and short-term
training on page 4. Complete all the items in Sections I and II. PRINT OR TYPE the application and submit the original and 2 photocopies
to your immediate supervisor.
TYPE OF TRAINING FOR WHICH YOU ARE APPLYING
Short-Term: See definitions on page 4. Do NOT use this form. Use form
HHS-350.
Long-Term: Application should be made for complete period of training.
Specify length below:
Full-Time
Part-Time
State field of study or specialty:
Sub specialty:
RESIDENCY APPLICANTS ALSO COMPLETE THE FOLLOWING:
Intramural
Extramural
Will Accept Either
IF TRAINING REQUESTED IS INTRAMURAL, WILL IT INVOLVE ANY EXTRAMURAL
TRAINING: HOW MUCH:
FULL NAME (First, Middle, Last)
SOCIAL SECURITY NO.
PRESENT MAILING ADDRESS (Official duty station)
DIVISION BUREAU BUSINESS PHONE
PHS SERIAL NO.
DATE OF BIRTH
(mm/dd/yyyy)
TYPE OF APPT.
Regular
Reserve
GRADE
DATE ENTERED ON DUTY
IN PHS (mm/dd/yyyy)
OBLIGATED MILITARY SERVICE
COMPLETION DATE (mm/dd/yyyy)
CATEGORY (Medical, etc.)
PRESENT ASSIGNMENT (Indicate your title and brief description of your duties)
PLACE TRAINING DESIRED (List in order of preference)
INSTITUTION OR HOSPITAL CITY and STATE FROM TO
APPROX.
TUITION
FEES
APPROX.
TRAVEL
COSTS
APPROX.
PER DIEM
COSTS
OTHER
COSTS
1.
2.
3.
DESCRIPTION OF TRAINING DESIRED (Attach announcement if possible)
REASONS TRAINING REQUESTED (Relate to present and future needs of the Commissioned Corps of the U.S. Public Health Service)
APPLICANT CERTIFICATION (Sign appropriate statement)
1. INTRAMURAL TRAINING AGREEMENT:
If HHS-supported intramural training program includes one or more periods of extramural training (i.e., training received in non-HHS facilities), I
voluntarily agree to serve on active duty with the Commissioned Corps of the U.S. Public Health Service (Corps) for 6 months or twice the period of
training received in non-HHS facilities, whichever is greater, subject to the following limitations: (a) If the total period of training in non-HHS facilities is
30 days or less, I incur no active-duty obligation; (b) Up to 1 year of training in non-HHS facilities, for which no tuition and fees are charged, shall be
disregarded in determining the period of myactive-duty obligation. My active-duty obligation shall commence immediately upon cessation of my
participation in the training program. Failure to fulfill my active-duty obligation shall subject me to the penalties set forth in Paragraph B, below. (See
CC25.2.3 of the electronic Commissioned Corps Issuance System (eCCIS.))
2. EXTRAMURAL TRAINING AGREEMENT:
I voluntarily agree to serve on active duty with the Corps for 6 months or twice the period of training, whichever is greater, for any period of HHS-
supported extramural training which exceeds 30 days (or part-time equivalent) and which is not part of an HHS intramural training program. My active-
duty obligation shall commence immediately upon cessation of my participation in the training program. Failure to fulfill my active-duty obligation shall
subject me to the penalties set forth in Paragraph B, below. (See CC25.2.1 and CC25.2.2 of the eCCIS.)
A. I understand the Department of Health and Human Services (HHS) policy prohibits acceptance of contributions to salary, from whatever source, by active-
duty officers, unless the contributions are accepted to the benefit of the Government and are deposited to the Miscellaneous Receipts of the Treasury of
the United States. Further, with regard to the training I receive, I have read and agree to the following:
B.
I understand that if I fail to complete an active-duty obligation with the Corps incurred as a result of my extramural training as set forth in Paragraph A 1
and 2, above, I shall be obligated to pay HHS an amount equal to two (2) times the total amount of tuition, fees, and other training expenses, and two (2)
times any compensation (to include but not limited to pay, allowances, special pays, travel, transportation, and shipment of household goods) received by
or paid to me in connection with the training. Furthermore, I understand that if I fail to fulfill an active-duty obligation incurred pursuant to my participation in
training under this agreement, HHS will deny lump sum payment of unused annual leave to my credit; divest me of any entitlements to travel and
transportation allowances and travel time which are otherwise authorized in connection with separation from the Corps; withhold my final pay and
allowances to satisfy any indebtedness to the Government; and deny my request for a commission in the inactive reserve.
SIGNATURE DATE
PHS-1122-1 (Rev. 08/16)
Page 1 of 4
PSC Publishing Services (301) 443-6740
EF
click to sign
signature
click to edit
SECTION II - TO BE COMPLETED BY APPLICANTS FOR RESIDENCY AND LONG-TERM TRAINING ONLY
EDUCATION AND PROFESSIONAL TRAINING
NAME OF UNIVERSITY, COLLEGE,
OR PROFESSIONAL SCHOOL
CITY and STATE
DATES ATTENDED
FROM
DATES ATTENDED
TO
MAJOR DEGREE
OTHER SPECIAL TRAINING (Such as internships, residencies, etc.)
INSTITUTION OR HOSPITAL CITY and STATE
DATES ATTENDED
FROM
DATES ATTENDED
TO
DESCRIPTION OF TRAINING
(e.g., type of internship)
ADDITIONAL QUALIFICATIONS
STATES AND DATES OF PROFESSIONAL LICENSURE, INCLUDE TYPE AND LICENSE NUMBER.
HAVE YOU HAD ANY TRAINING WHICH WILL BE ACCEPTED BY THE AMERICAN SPECIALTY BOARD OF YOUR CHOICE? (If yes, submit evidence
from the Board as to the amount with which you will be credited next July 1.)
Yes (How much? No. years:
No. months:
)
No
OTHER SKILLS AND QUALIFICATIONS
TITLE OF POSITION
OPERATING DIVISION / STAFF
DIVISION / NON-HHS ORGANIZATION
BUREAU
DATES OF
ASSIGNMENT FROM
DATES OF
ASSIGNMENT TO
REFERENCES (List the names of four persons with whom you have had professional affiliation and who are in a position to evaluate your qualifications for
the training requested. Do not include your immediate superior. If applying for residency, include senior staff members and officers in charge of hospitals
where you served as intern or resident.)
FULL NAME STREET CITY STATE ZIP CODE
PHS-1122-1 (Rev. 08/16)
Page 2 of 4
SECTION III - ACTION TAKEN ON APPLICATION
RECOMMENDATION OF IMMEDIATE SUPERVISOR
Approval
Disapproval
TITLE STATION
REASONS FOR APPROVAL OR DISAPPROVAL (Use page 4 if additional space is needed and check here
)
SIGNATURE OF IMMEDIATE SUPERVISOR DATE
RECOMMENDATION OF BRANCH CHIEF
NONDISCRIMINATION CERTIFICATION: It has been duly ascertained that the training institution(s) named in Section I, Item 14, do(es)
not discriminate because of race, color, or national origin in the admission or in the subsequent treatment of students. This officer has been
recommended for training without regard to race, creed, color, national origin, or gender.
Approval
Disapproval
IS FINANCIAL SUPPORT
AVAILABLE AT INITIATING LEVEL?
Yes
No
IS TRAINING JUSTIFIED BY THE
NEEDS OF THE SERVICE?
Yes
No
CAN APPLICANT BE RELEASED
TO TAKE THIS TRAINING?
Yes
No
HOW WOULD THE TRAINING BENEFIT THE SERVICE?
SIGNATURE OF BRANCH CHIEF
BRANCH DATE
RECOMMENDATION OF DIVISION OR OFFICE DIRECTOR
Approval
Disapproval
IS FINANCIAL SUPPORT AVAILABLE?
Yes
No
HOW WOULD THE TRAINEE’S SERVICES BE USED?
REASONS FOR APPROVAL OR DISAPPROVAL
SIGNATURE OF DIVISION OR OFFICE DIRECTOR
DIVISION OR OFFICE DATE
RECOMMENDATION OF CENTER, BUREAU, OR INSTITUTE DIRECTOR
Approval
Disapproval
IS FINANCIAL SUPPORT AVAILABLE?
Yes
No
REASONS FOR APPROVAL OR DISAPPROVAL
SIGNATURE OF BUREAU OR INSTITUTE DIRECTOR
BUREAU OR INSTITUTE DATE
COMMITTEE ACTION (Forward to Division of Commissioned Corps Personnel and Readiness, Assignments and Career Management Branch/
Assignments, 1101 Wootton Parkway, Plaza Level, Suite 100, Rockville, MD 20852).
Approval
Disapproval
SIGNATURE OF CHAIRPERSON
DATE
REASONS FOR RECOMMENDATION
DCCPR/ACM AND/OR DCCTCD RECOMMENDATION
IMMEDIATE OFFICE OF THE DIRECTOR, DCCPR, ACTION
Approval
Disapproval
SIGNATURE OF DIRECTOR, DCCPR
DATE
PHS-1122-1 (Rev. 08/16)
Page 3 of 4
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
DEFINITIONS OF TYPE OF TRAINING
LONG-TERM TRAINING: Long-term training includes all units or courses in a planned educational program leading to an
academic degree, whether taken full-time, part-time, continuously, or intermittently. (If the amount of training to be taken
during any one academic term or fiscal year falls within the limits of short-term training but still meets this definition, it will be
processed as long-term training.) Long-term training also includes internship or residency training the period for which
exceeds that specified as short-term training (see below).
SHORT-TERM TRAINING: Training outside the Department of Health and Human Services in non-Government institutions
and facilities which does not lead to an academic degree. However, such training must be within the following limits: full-time
training that does not exceed 30 consecutive days or a total of 90 calendar days in a fiscal year; part-time training that does
not exceed 70 hours in attendance within a 30-day period or a total of 210 hours in a fiscal year. Use form HHS-350 for this
type of training.
INSTRUCTIONS FOR ROUTING APPLICATION
Applicant - Complete the application. Submit the original and two photocopies to your immediate supervisor.
Supervisor - Complete item 22 on all copies, and forward to the Branch Chief.
Branch Chief - Complete item 23 on all copies and forward as indicated.
REMARKS
PRIVACY ACT STATEMENT FOR FORM PHS-1122-1
This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). Our authority to collect this information from you is 42 U.S.C.
218a.
Principal Purpose and Routine Uses
The information you provide on this form will be used to determine whether the training you request will be sponsored by HHS. This form also
serves as a record of the service agreement you willingly incur in return for HHS-sponsored training. This information will be used only as
necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of
records. Copies of these systems of records may be obtained by contacting the office where you submitted this form.
Record System
09-40-0001, PHS Commissioned Corps General Personnel Records, HHS/PSC/HRS; 09-40-0003, PHS Commissioned Corps Board
Proceedings, HHS/PSC/HRS; 09-40-0004, PHS Commissioned Corps Grievance, Investigatory and Disciplinary Files, HHS/PSC/HRS;
09-40-0006, PHS Commissioned Corps Payroll Records, HHS/PSC/HRS; 09-40-0010, Pay, Leave and Attendance Records,
HHS/PSC/HRS; and 09-40-0011, Proceedings of the Board for Correction of PHS Commissioned Corps Records, HHS/PSC/HRS.
Information Regarding Disclosure of Your Social Security Account Number
Disclosure of your Social Security Number (SSN) is mandatory under provisions of Executive Order 9397 to obtain benefits and services as
an officer in the Commissioned Corps of the U.S. Public Health Service (Corps). Your SSN is also used to distinguish your record from those
of Corps officers who may have similar names and dates of birth.
Effects of Non-Disclosure
You must disclose your SSN as explained above. If you do not provide the information requested on this form, you will not be considered for
HHS sponsored training.
PHS-1122-1 (Rev. 08/16)
Page 4 of 4
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Phs-1122-1 FORM PHS 1122-1

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document