OMB Approved

Form No. 0917-0028

Expiration Date: 11/0/201!
Addend"m to De#$aration %or Federa$ Emp$o&ment 'OF 0()
*ndian +ea$t, -ervi#e
.,i$d .are / *ndian .,i$d .are 0or1er 2o3ition3
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*tem 1(. A4en#& -pe#i%i# 5"e3tion3
Name: 666666666666666666666666666 -o#ia$ -e#"rit& N"m7er: 666666666666666666
'2$ea3e print)
8o7 9it$e in Anno"n#ement: 66666666666666666666 Anno"n#ement N"m7er: 66666666666
Section 231 of the Crime Control Act of 1990, Public Law 101-64, re!uire" that em#lo$ment
a##lication" for in%i&i%ual" "ee'in( em#lo$ment in a #o"ition in&ol&e% with the #ro&i"ion to
chil%ren un%er the a(e of 1) of *chil% care "er&ice",+ a" %efine% in 42 ,-S-C- 13041.a/.2/, contain
a !ue"tion a"'in( whether the in%i&i%ual ha" e&er been arre"te% for or char(e% with a crime
in&ol&in( a chil% an% for the %i"#o"ition of the arre"t or char(e- ,n%er 42 ,-S-C- 13041.a/.2/, the
term 0chil% care "er&ice"0 mean" chil% #rotecti&e "er&ice" .inclu%in( the in&e"ti(ation of chil%
abu"e an% ne(lect re#ort"/, "ocial "er&ice", health an% mental health care, chil% .%a$/ care,
e%ucation .whether or not %irectl$ in&ol&e% in teachin(/, fo"ter care, re"i%ential care, recreational
or rehabilitati&e #ro(ram", an% %etention, correctional, or treatment "er&ice". 1n%i&i%ual" hire%
for "uch #o"ition" mu"t un%er(o a criminal hi"tor$ bac'(roun% chec'-
Section 40) of the 1n%ian Chil% Protection an% 2amil$ 3iolence Pre&ention Act, Public Law 101-
630, contain" a relate% re!uirement for #o"ition" in the 4e#artment of 5ealth an% 5uman Ser&ice"
that in&ol&e re(ular contact with or control o&er 1n%ian chil%ren- 6he a(enc$ mu"t en"ure that
#er"on" hire% for the"e #o"ition" ha&e not been foun% (uilt$ of or #lea%e% nolo conten%ere or
(uilt$ to certain crime"- 6he law re!uire" that the a(enc$ con%uct an in&e"ti(ation of the
character of each in%i&i%ual who i" bein( con"i%ere% for em#lo$ment in "uch a #o"ition an%
#re"cribe in re(ulation" the *minimum "tan%ar%" of character+ that mu"t be met in or%er for an
in%i&i%ual to fill "uch a #o"ition- 6he re(ulation" "#ecif$ that *7t8he minimum "tan%ar%" of
character "hall be con"i%ere% met onl$ after the in%i&i%ual ha" been the "ub9ect of a "ati"factor$
bac'(roun% in&e"ti(ation,+ which inclu%e" a criminal hi"tor$ bac'(roun% chec'- 42 C-2-:- ;
136-406-
6o a""ure com#liance with the abo&e law", the followin( !ue"tion" are a%%e% to the 4eclaration
for 2e%eral <m#lo$ment=
1- 5a&e $ou e&er been arre"te% for or char(e% with a crime in&ol&in( a chil%>
YES_____ NO______
[If 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.
OMB Approved
Form No. 0917-0028
Expiration Date: 11/0/201!
2- 5a&e $ou e&er been foun% (uilt$ of, or entere% a #lea of nolo conten%ere .no conte"t/ or
(uilt$ to, an$ feloniou" or mi"%emeanor offen"e un%er 2e%eral, State, or tribal law
in&ol&in( crime" of &iolence? "e@ual a""ault, mole"tation, e@#loitation, contact or
#ro"titution? or crime" a(ain"t #er"on"? or offen"e" committe% a(ain"t chil%ren>
YES______ NO______
[If 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.
1 certif$ that .1/ m$ re"#on"e to the"e !ue"tion" i" ma%e un%er #enalt$ of #er9ur$, which i"
#uni"hable b$ fine un%er title 1) of the ,-S- Co%e, or im#ri"onment of not more than fi&e $ear",
or both? an% .2/ 1 ha&e recei&e% notice that a criminal chec' will be con%ucte%- 1 un%er"tan% m$
ri(ht to obtain a co#$ of an$ criminal hi"tor$ re#ort ma%e a&ailable to the 1n%ian 5ealth Ser&ice
an% m$ ri(ht to challen(e the accurac$ an% com#letene"" of an$ information containe% in the
re#ort-
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA666666666666
App$i#ant:3 -i4nat"re '3i4n in in1) Date
!u"lic #urden Statement$ In accordance %ith !aper%or& 'eduction (ct [) *+' ,-./.0 1"21-2, a +ederal agenc3 ma3 not
conduct or sponsor, and a person is not re4uired to respond to, a collection of information unless it displa3s a currentl3 valid
O5# control num"er. 'espondents must "e informed 1on the reporting instrument, in instructions, or in a cover letter2 the
reasons for %hich the information %ill "e collected6 the %a3 the information %ill "e used to further the proper performance of
the functions of the agenc36 %hether responses to the collection of the information are voluntar3, re4uired to o"tain a "enefit
1citing authorit32, or mandator3 1citing authorit326 and the nature and extent of confidentialit3 to "e provided, if an3 1citing
authorit32. !u"lic reporting "urden for this collection of information is estimated to average ,. minutes per response,
including time for revie%ing instructions, searching existing data sources, gathering and maintaining the necessar3 data, and
completing and revie%ing the collection information. Send comments regarding the "urden estimate or an3 other aspect of this
collection of information to the I7S !'( Information *ollection *learance Staff, ,.-// 8%in"roo& !ar&%a3, Suite 9)/,
'oc&ville, 5: ./0).. Please do not send completed data collection instruments to this address.