Employee Clearance Checklist



(08/2013)DEPARTMENT OF HEALTH AND HUMAN SERVICESIndian Health ServiceEMPLOYEE CLEARANCE CHECKLISTEMPLOYEE NAME: (First, Middle, Last)LAST 4 DIGITS OF SSN:TIMEKEEPER NUMBER: FORMTEXT ????? FORMTEXT ???? FORMTEXT ?????NAME OF ORGANIZATION AND WORK LOCATIONFORWARDING ADDRESS FORMTEXT ?????Street or PO Box FORMTEXT ?????CityStateZIP Code FORMCHECKBOX Separating from the Federal Government FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMCHECKBOX Transferring to another IHS Component or Federal GovernmentHOME TELEPHONE (optional)(Specify): FORMTEXT ????? FORMTEXT ?????HOME EMAIL ADDRESS (optional)DATE OF SEPARATION OR TRANSFER: FORMTEXT ????? FORMTEXT ?????ITEMSRECEIVED FROM EMPLOYEECHECK ONE(If yes, identify the accountable office* in comments field. If no, please explain.)COMMENTS*ACCOUNTABLE OFFICE FOR FINAL DISPOSITIONInitialDate1IT Access Control Removed(Network – Email – RPMS) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????2Advanced Leave Resolved FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????3PIV Card Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????4Non-PIV Facility Access Cards Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????5Keys Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????6Official Files and Records Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????7Government Purchase Card (PCard) Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????8Travel Card Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????9Outstanding Travel Advance Resolved FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????10Outstanding Travel Voucher Resolved FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????11E-Gov Travel Service Access Removed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????12Library Books/Card Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????13UFMS Access Removed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????14Government Hang Tag/Parking Sticker Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????15Government Phone Cards Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????16Government Emergency Telecommunications Service (GETS) Card Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????Continue on Page 2(08/2013)DEPARTMENT OF HEALTH AND HUMAN SERVICESPage 2 – ContinuationIndian Health ServiceEMPLOYEE CLEARANCE CHECK LISTEMPLOYEE NAME: (First, Middle, Last)LAST 4 DIGITS OF SSN:TIMEKEEPER NUMBER REF Text1 \* MERGEFORMAT REF Text2 \* MERGEFORMAT REF Text3 \* MERGEFORMAT ITEMSRECEIVED FROM EMPLOYEECHECK ONE(If yes, identify the accountable office* in comments field. If no, please explain.)COMMENTS*ACCOUNTABLE OFFICE FOR FINAL DISPOSITIONInitialDate17Government Cell Phone Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????18Smart Phone, Palm Pilot, Blackberry, iPhone Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????19Laptop Computer Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????20Government Pager Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????21Other Government Furnished Equipment Returned FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????22Separation Data Entered into ITAS FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????23Supervisor Initiated Capital HR Appropriate Action FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????24Capital HR Request Approved FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????25Action Tracking System (ATS) Access Removed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????26E-WITS (if applicable) Removed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????27PRISM Access Removed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????Under comments, list the office that was sent the item or notified about clearing it. Accountable offices may differ.If the employee is not willing to sign the clearance sheet, not present or deceased, the supervisor should locate all equipment assigned to the employee and account for each piece on the clearance sheet. For any missing items take the appropriate action.Additional Comments: FORMTEXT ?????I certify that I do not have IHS property or records in my possession and that I am not indebted to the IHS.I certify that I have completed this form and that I have verified that all required clearances have been obtained.Signature of EmployeeDateSignature of SupervisorDateDistribution:Completed original to the Director of Division of Human Resources (DHS) or the Regional Human Resource Office (RHRO)1 copy to the employee1 copy to the supervisor ................
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