AGREEMENT
To Receive An Allowance Under the Federal Physicians Comparability Allowance Program (5 U.S.C. 5948)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
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before completing this agreement
NAME (Print or Type)
AGENCY
In consideration of payments of the allowance for which I qualify under the Federal Physicians Comparability Allowance (PCA) Program (5 U.S.C. 5948) as
implemented by the Regulations of the Office of Personnel Management (5 CFR Part 595), the policies of the Department of Health and Human Services, and
the Public Health Service, I hereby agree:
To serve in
(agency)
, PHS for
one two years in a position(s) designated as Category Subcategory Tier .
That the amount of allowance payable to me shall be determined by the Assistant Secretary for Health or his designee as prescribed by the HHS plan for
payment of such allowances. The allowance payable under this agreement is $
per year for
year(s).
That if I elect to enter into a two-year contract, the Assistant Secretary for Health or his designee may limit this agreement to one year if it has been determined
that the category or subcategory to which I am assigned will not have recruitment or retention problems after the one year period.
That acceptance of this agreement does not alter the conditions or terms of my employment.
That my entitlement of this allowance is based solely on the position to which I am assigned and is not associated with my performance and/or conduct.
Accordingly, this agreement will not preclude nor limit the Public Health Service’s right to take corrective or disciplinary actions as may be appropriate.
(a) That in the event I voluntarily or because of misconduct fail to complete at least one year of service in a position which entitles me to receive the
allowance, I will refund the amount of the allowance I have received unless the Assistant Secretary for Health, in accordance with prescribed regulations,
determines that my failure to complete my agreed period of service is due to circumstances which are beyond my control.
(b) That in the event I voluntarily or because of misconduct fail to complete the second year of a two-year agreement in a position which entitles me to receive
the allowance, I will refund the amount of the allowance I received under this agreement for the 26 weeks of service immediately preceding the termination
unless the Assistant Secretary for Health determines that my failure to complete my agreed period of service is due to circumstances which are beyond
my control.
(c) It is further agreed that any amount which I am obligated to refund under (a) or (b) of this paragraph will be a debt due to the United States which I hereby
agree to pay in full as directed by the Department of Health and Human Services.
That the effective date of this agreement and payments pursuant to this agreement will normally commence on the first day of the pay period after the following
conditions are met:
(a) My position of record is approved by the Assistant Secretary for Health as one of a category or subcategory for which recruitment and retention problems
exist; and
(b) The agreement is signed and notarized.
In unusual circumstances, such payments will commence on a later date specified by me or a date specified by the agency which is
.
That my entitlement to the allowance under this agreement will terminate when any of the following occur:
(a) Cessation of employment with the Public Health Service.
(b) Assignment to a position excluded from PCA coverage or not approved for PCA.
(c) Completion of agreed period of service or enactment of superseding law.
(d) Change of tour of duty to less than half-time.
(e) October 1, 1990 or any subsequent date established by law.
(This section is appliacable only to individuals who have served in a health professionals shortage area and have signed a contract with the Federal Government
to serve in such an area in return for Government paying all or part of a student loan.)
That the amount equivalent to any loan repaid under a Federally supported loan repayment program will reduce the allowance for which I would otherwise be
eligible under applicable regulations and instructions. That failure to report a repayment contract now in effect or which becomes effective during the period of
this agreement will result in my obligation to refund the amount of allowance I have received. I am
am not
participating in a Federally supported
loan repayment program. The amount that has or will be repaid by this loan repayment agreement is:
$
for the period to
.
That the regulations and policies implementing 5 U.S.C. 5948 are incorporated into and made a part of this agreement and I have read these regulations and
policies.
I am board certified in the following medical specialty or specialties:
Specialty
Date of Certification
I AGREE TO THE TERMS OF THIS CONTRACT
SIGNATURE Print/Type Name Social Security Number Date
NOTARIZATION
Subscribed and sworn before me this day of
A.D. at
(City and State)
Zip Code
SIGNATURE OF NOTARY
Date Commission Expires
PHS 6106 (Rev. 09/88)
Page 1
PSC Publishing Services (301) 443-6740
EF
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