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UNIFORMEDSERVICESU
NIVERSITY
of the Health Sciences, Civilian Human Resources
Manager’s Guide for Staffing & Classification Actions
1. FACT SHEETS
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Fact Sheet - Request for Personnel Action (RPA) for GS & FWS Recruitment Action.
Fact Sheet - RPA for GS & FWS Reassignment Action.
Fact Sheet - RPA for GS & FWS Career Ladder Promotion Action.
Fact Sheet - RPA for AD Recruitment Action.
Fact Sheet - RPA for Hiring Volunteers
2. SAMPLE – RPAs
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
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
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Sample RPA for GS & FWS Recruitment Action.
Sample RPA for GS & FWS Reassignment Action.
Sample RPA for GS & FWS Career-Ladder Promotion.
Sample RPA for AD Recruitment Action.
Sample RPA for Hiring Volunteers
3. FORMS & GUIDANCE




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
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Request for Personnel Action (RPA)-Fillable Form.
Instructions for Completing an RPA.
Position Description Cover Sheet (Optional Form 8-OF 8) with instructions – Fillable Form.
Sample OF 8.
Certification of Medical Examination (Optional Form 178 - OF 178).
CHR Recruitment Checklist.
Template for Justification Memorandum.
Administratively Determined (AD) Salary/Compensation Request Form.
Parental Permission Form
Work Permit Application
Volunteer Agreement Form (DD Form 2793)
Work Assignment for a Minor (USUHS Form 6050)
USUHS Instructions 6004 Minors Employed at the University
Revised: 16 November 2012
UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Staffing and Classification
Fact Sheet
Request for Personnel Action (RPA) for GS/FWS Recruitment Actions
The following provides guidance and information on the appropriate documentation needed to
initiate a GS/FWS recruitment action.
•
Departments should consult with their designated CHR Staffing & Classification
Specialist to discuss the position and available hiring options before submitting a
recruitment action to the CHR.
•
Supervisors should review the subject position description (PD) to ensure that it is
accurate before submitting a recruitment action.
•
The department will prepare a RPA for the recruitment action and will include the
following information. See sample RPA for GS/FWS recruitment action and the
instructions for completing an RPA - Sections 2 and 3.
 Indicate on the RPA if the position is new or vice an employee that separated.
 The RPA must be signed and dated by the immediate supervisor and authorized by
the appropriate Chair, Department/Activity Head, or higher level official in the
chain of command.
 Completed Recruitment Checklist (See CHR Recruitment Checklist - Section 3)
•
When the position is a vice recruitment action, the following documents will also be
required and must accompany the RPA:
 A copy of the position description (PD) including the completed PD cover sheet
(Optional Form - OF 8).
 If the position is a career ladder position, include appropriate grade level PDs (with
OF 8) and statement(s) of difference. See sample OF 8 with instructions - Section
3.
 If the position is a WS, WL, or WG position or a position that requires a medical
exam include the Certification of Medical Examination Form (OF178), if
applicable. See copy of OF 178 - Section 3.
•
When the position is new, re-described, or a restructure of the grade level of a vice
position, the following documents will be required and must accompany the RPA:
 A copy of the new and old PDs including completed PD cover sheets (OF 8). See
sample OF 8 - Section 3.
 A written justification for initiating the new position, redescription, or restructure
of the vice position to include how the department expects to fund the position if
additional funds are required. See justification memorandum template - Section 3.
13 April 2012
Page 1
RPA for GS/FWS Recruitment Actions
Fact Sheet
 A current and proposed organizational chart of the subject department or division
showing the location of the new or restructured position.
 If the position is a career ladder position include appropriate grade level PDs (with
OF 8) and statement(s) of difference.
 If the position is a WS, WL, or WG position or a position that requires a medical
exam include an OF178, if applicable.
•
The department will submit the recruitment action to the CHR-Staffing & Classification
Division for review and processing.
Note: All RPAs must be signed and dated. RPAs received with incomplete or inaccurate
information will be returned to the originator.
13 April 2012
Page 2
UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Staffing and Classification
Fact Sheet
Request for Personnel Action (RPA) for GS/FWS Reassignment Actions
The following information provides guidance on the appropriate documentation needed to initiate
a GS/FWS reassignment action:
•
Departments should consult with their designated CHR Staffing & Classification
Specialist to discuss the process of reassigning an employee before submitting the
reassignment action.
•
The department will prepare an RPA for the reassignment action (an assignment to a
position at the same grade level). See Sample RPA for GS/FWS reassignment action and
the instructions for completing an RPA - Sections 2 and 3.
 The RPA must be signed and dated by the immediate supervisor of the employee’s
current position and signed by the appropriate Chair, Department/Activity Head or
higher level official in the chain of command.
•
The following documents will be required and must accompany the RPA.
 A copy of the position description (PD) including the PD cover sheet (OF 8) to
which the employee will be reassigned. See sample OF 8 - Section 3.
 Annotate any special requirements in Part D of the RPA (e.g. security clearance,
drug test, physical, DAWIA, etc).
•
The department will submit the RPA for the reassignment action to CHR, Staffing &
Classification Division, for review and processing.
Note: All RPAs must be signed and dated. RPAs received with incomplete or inaccurate
information will be returned to the originator.
13 April 2012
Page 1
UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Staffing and Classification
Fact Sheet
Request for Personnel Action (RPA) for GS/FWS Career Ladder Promotion Actions
The following information provides guidance on the appropriate documentation needed to initiate
a GS/FWS Career Ladder Promotion action.
•
Departments should consult with their designated CHR Staffing & Classification
Specialist to discuss the requested career ladder promotion before submitting an RPA.
•
The department will prepare an RPA for the promotion action. See sample RPA for career
ladder promotion action and the instructions for completing an RPA - Sections 2 and 3.
 The RPA must be signed and dated by the immediate supervisor of the employee and
signed by the appropriate Chair, Department/Activity Head or higher level official in
the chain of command.
•
The following documents are required and must accompany the RPA.
 A copy of the higher graded position description (PD) to which the employee is being
promoted including the Optional Form (OF8).
 An email or brief memorandum to CHR from the immediate supervisor stating that the
employee meets the proficiency level required for advancement to the next higher
grade level of his/her position.
•
The department will submit the RPA for the promotion action to the CHR, Staffing &
Classification Division, for review regulatory sufficiency and processing.
Note: The RPA must be signed and dated. RPAs received with incomplete or inaccurate
information will be returned to originator.
13 April 2012
Page 1
UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Staffing and Classification
Fact Sheet
Request for Personnel Action (RPA) for AD Recruitment Actions
The following provides guidance and information on the appropriate documentation needed to
initiate an AD recruitment action.
•
Departments should consult with their designated CHR Staffing & Classification
Specialist to discuss the position and available hiring options before submitting a
recruitment action to the CHR.
•
Supervisors should review the subject position description (PD) to ensure that it is
accurate before submitting a recruitment action.
•
Department will prepare a RPA for the recruitment action and include the following
information. See sample RPA for AD recruitment action and the instructions for
completing an RPA - Sections 2 and 3.
 The RPA will specify if the position is new or vice an employee that separated.
 The RPA will specify if the position is in the tenure track or the non-tenured track.
 The RPA must be signed by the department Chair or head and authorized/signed
by the appropriate Dean, Vice President, Director of AFRRI, or the President.
•
If the position is a vice recruitment action, the following will be required and must
accompany the RPA:
 A copy of the position description (PD) including the completed PD cover sheet
(Optional Form - OF 8).
 A draft of the proposed advertisement.
•
If the position is new or a restructure in the academic rank (e.g., Assistant Professor to
Associate Professor, etc.) of a vice position, the following will be required and must
accompany the RPA:
 A copy of the new and old PDs including completed PD cover sheets (OF 8). See
sample OF 8 - Section 3.
 A justification memorandum for initiating the new position or restructure of the
vice position to include how the department expects to fund the position if
additional funds are required. See justification memorandum template - Section 3.
 A current and proposed organizational chart of the subject department or division
showing the location of the new or restructured position.
 A draft of the proposed advertisement
13 April 2012
Page 1
RPA for AD Recruitment Actions
•
Fact Sheet
The CHR, Staffing & Classification Division, will review and process the RPA upon
receipt.
Note: All RPAs must be signed and dated. RPAs received with incomplete or inaccurate
information will be returned to the originator.
13 April 2012
Page 2
Staffing and Classification
Fact Sheet
UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Request for Personnel Action (RPA) for Hiring Volunteer The following provides guidance and information on the appropriate documentation needed to
initiate a volunteer recruitment action. Agencies must document service performed without
compensation by persons who do not receive a Federal appointment and are required to inform
volunteers of the nature of their appointments.

The department will prepare a Request for Personnel Action (RPA) for the recruitment
action. See Section 3 for sample forms and guidance.
 Indicate the Not to Exceed (NTE) date of no more than one (1) year on Block 1“Action Requested” of the RPA.
 The RPA must be signed and dated by the immediate supervisor and authorized by
the appropriate Chair, Department/Activity Head, or higher level official in the
chain of command.
 The RPA must be submitted at least seven (7) working days prior to entrance on
duty (EOD) to provide sufficient time to coordinate the action with the appropriate
USU departments (i.e. Security, Environmental Health & Occupational Safety, and
the Learning Resources Center).
 CHR, Staffing & Classification Division, will coordinate the entrance on duty date
(EOD). All RPAs received must be signed and dated. RPAs with incomplete or
inaccurate information will be returned to the originator.

The following completed documents are required and must accompany the RPA:
 Form DD-2793 (Volunteer Agreement), Parts I and II, http://www.usuhs.mil/chr/doc/DD‐
2793.pdf. See Section 3, Forms and Guidance.
 A copy of the volunteer’s resume/cv.

Submit the completed RPA, DD-2793, and resume/cv to CHR.
FOR MINORS

If the volunteer is a minor (17 or younger), the following additional documents will be
required and must accompany the RPA:
16 November 2012 Page 1 RPA for
Hiring a Volunteer
Fact Sheet
 Work Permit Application along with proof of age document. See Section 3, Forms
and Guidance. The CHR must receive the individual’s work permit before
employment begins.
 Permission from the school the volunteer is presently attending. Permission from
the school is only required during the school year. If required, the letter must be on
school’s letterhead.
 Parental Permission Statement (signed and dated). See Section 3, Forms and
Guidance.
 USUHS Form 6050- Work Assignment for a Minor. See Section 3, Forms and
Guidance.
 If the volunteer is below 16 years of age, an exception to the age requirement
must be approved by Environmental Health & Occupational Safety (EHS). See
Section 3, Forms and Guidance.
 Minors working in Laboratories: Minors younger than 16 will not be allowed to
work in “posted” laboratories. Minors between the ages of 16 and 18 may be
allowed to work in “posted” laboratories with the permission of the USUHS
Radiation Safety Officer (RSO), 301-295-3390. See Section 3, Forms and
Guidance.
EXTENDING VOLUNTEER APPOINTMENTS

The department will prepare an RPA to request an “Extension of Appointment” and
indicate the new Not to Exceed (NTE) date. The NTE date may not be more than one year.

The RPA must state the reason/rationale for extension in Part D, Remarks by the requesting
office.

The RPA must be signed and dated by the immediate supervisor and authorized by the
appropriate Chair, Department/Activity Head, or higher level official in the chain of
command.

Submit the RPA (Request for Extension) to CHR at least 30 days prior to the expiration of
the original appointment.
IN-PROCESSING PROCEDURES

Volunteers will report to Civilian Human Resources (CHR), Building A, room A1022.
16 November 2012 Page 2 Staffing and Classification
Fact Sheet
Fact Sheet
CHR will in-process volunteer personnel only on Mondays (10:00 to 11:00 A.M.) and
RPA for
Hiring a Volunteer

Wednesdays (9:00 to 10:00 A.M.). All EODs must be coordinated with CHR at least 7
working days prior to the effective date.

Volunteers are required to provide one the following valid forms of identification during
in-processing. Expired documents will not be accepted.
 U.S. Citizens: Birth Certificate, U.S. Passport, or Social Security Card with a valid
Driver’s License or State ID.
 Non-U.S. Citizens: Permanent Resident Card (green card), Employment Authorization
Card or VISA authorizing permission to work in the U.S.

Volunteers will receive a CHR check-in sheet for reporting to the departments listed
below:
 USUHS/AFRRI Security Office
 USUHS Environmental Health & Occupational Safety Office (EHS)

Volunteers must return the check-in sheet to the CHR. Failure to return the form will
relieve USUHS of any responsibility for the volunteer.
OUT-PROCESSING PROCEDURES

All Volunteers must out-process through CHR at least 3 work days prior to the end of
their service.

The supervisor of the volunteer employee must complete Part IV of Form DD-2793
(Volunteer Agreement) at the end of the volunteer employee’s service and return the form
to CHR.
ADDITIONAL INFORMATION CONCERNING VOLUNTEER EMPLOYMENT

Volunteers may not supervise paid employees or military personnel.

Volunteers may not be used to displace paid employees, or in lieu of filling authorized
paid personnel positions.

Volunteers are considered employees of the Federal government only for the following
purposes:
 Concerning compensation for the disability or death of an employee resulting from
personal injury sustained while in the performance of his/her duty.
16 November 2012 Page 3 RPA for
Hiring a Volunteer
Fact Sheet
 Regarding the maintenance of records on individuals that are contained in a
Privacy Act system of records.
 Criminal laws relating to conflicts of interest (18 U.S., Chapter 11).
 Defense of certain suits arising out of alleged legal malpractice under Title 10
U.S.C. 1054

The CHR will retain volunteer records for three (3) years following the termination of
volunteer service.

Any questions regarding volunteer appointments should be addressed to the CHR, Staffing
and Classification Division, at (301) 295-3412.
16 November 2012 Page 4 Sample RPA for GS/FWS Recruitment Actions
Standard Form 52
Rev. 7/91
U.S. Office of Personnel Management
FPM Supp. 296-33, Subch. 3
REQUEST FOR PERSONNEL ACTION
PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
2. Actions Requested
Recruit/Fill – New (or) Vice Jane Doe (include employee’s name on vice actions)
MED-11-001
3. For Additional Information Call (Name and Telephone Number)
4. Proposed Effective Date
John Doe, (301) 295-1234
1 June 2011
5. Action Requested By (Typed Name, Title, Signature, and Request Date)
6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Immediate Supervisor, Director of ___, MED & Date
Authorizing Official, Chairperson, MED & Date
PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
FIRST ACTION
SECOND ACTION
5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
3. Date of Birth
4. Effective Date
15. TO: Position Title and Number
Program Specialist
PD# F444A
8. Pay Plan
9. Occ. Plan
12A. Basic Pay
10. Grade or Level
11. Step or Rate
12B. Locality Adj.
12. Total Salary
12C. Adj. Basic Pay
13. Pay Basis
12D. Other Pay
16. Pay
Plan
17. Occ.
Code
GS
0301
18. Grade or Level
20A. Basic Pay
14. Name and Location of Position’s Organization
19. Step or Rate
20. Total Salary
11
20B. Locality Adj.
20C. Adj. Basic Pay
21. Pay
Basis
20D. Other Pay
22. Name and Location of Position’s Organization
USUHS, School of Medicine
Department of Medicine, Nephrology Division
Bethesda, Maryland
EMPLOYEE DATA
23. Veterans Preference
1- None
3- 10-Point/Disability
2- 5-Point 4- 10-Point/Compensable
5- 10-Point/Other
6- 10-Point/Compensable/30%
24. Tenure
25. Agency Use
26. Veterans Pref for RIF
0- None
2- Conditional
1- Permanent 3- Indefinite
YES
27. FEGLI
30. Retirement Plan
31. Service Comp. Date (leave)
28. Annuitant Indicator
29. Pay Rate Determinant
32. Work Schedule
33. Part-Time Hours Per
Biweekly
Pay Period
F
POSITION DATA
34. Position Occupied
35. FLSA Category
1- Competitive Service
2- Excepted Service
1
3- SES General
4- SES Career
38. Duty Station Code
NO
36. Appropriation Code
37. Bargaining Unity Status
E- Exempt
N- Nonexempt
39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD
40. Agency
41.
45. Educational Level
46. Year Degree Attained
DDAAFD
42.
43.
44.
1BICDG
1BICDG
47. Academic Discipline
48. Functional Class
49. Citizenship
1- USA
50. Veterans Status
51. Supervisory Status
8 - Other
PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function
Initials/Signature
Date
Office/Function
A.
D.
B.
E.
C.
F.
2. Approval: I certify that the information entered on this form is accurate and that the
proposed action is in compliance with statutory and regulatory requirements.
Signature
CONTINUED ON REVERSE SIDE
52-118
OVER
Initials/Signature
Date
Approval Date
Editions Prior to 7/91 Are Not Usable After 6/30/93
NSN 7540-01-333-6239
Sample RPA for GS/FWS Recruitment Actions
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement?
If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
PART E – Employee Resignation/Retirement
YES
NO
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding
address. Your reason may be considered in any future decision regarding your re-employment in the
Federal service and may also be used to determine your eligibility for umemployment compensation
benefits. Your forwarding address will be used primarily to mail you copies of any documents you
should have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code.
Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and
their records, while section 8506 requires agencies to furnish the specific reason for termination of
Federal service to the Secretary of Labor or a State agency in connection with administration of
unemployment compensation programs.
The furnishing of the information is voluntary; however, failure to provide it my result in your not
receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you;
and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at
the end of the day – midnight – unless you specify otherwise.)
2. Effective Date
3. Your Signature
PART F – Remarks for SF 50
4. Date Signed
5. Forwarding Address (Number, Street, City, State, ZIP Code)
Sample RPA for GS/FWS Reassignment Actions
Standard Form 52
Rev. 7/91
U.S. Office of Personnel Management
FPM Supp. 296-33, Subch. 3
REQUEST FOR PERSONNEL ACTION
PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
2. Actions Requested
Reassignment
MED-11-001
3. For Additional Information Call (Name and Telephone Number)
4. Proposed Effective Date
JOHN DOE, (301) 295-1234
1 June 2011
5. Action Requested By (Typed Name, Title, Signature, and Request Date)
6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Immediate Supervisor, DVM, Director, MED & Date
Authorizing Official, Chair Person, DVM, MED & Date
PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
3. Date of Birth
4. Effective Date
Doe, Jane
FIRST ACTION
SECOND ACTION
5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
15. TO: Position Title and Number
Security Assistant
PD#A2913
8. Pay Plan
9. Occ. Plan
GS
080
12A. Basic Pay
10. Grade or Level
Security Assistant (OA)
PD# F444A
11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay
Plan
11
GS
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
18. Grade or Level
19. Step or Rate
20. Total Salary
11
080
20A. Basic Pay
14. Name and Location of Position’s Organization
20B. Locality Adj.
20C. Adj. Basic Pay
21. Pay
Basis
20D. Other Pay
22. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine
Department of Medicine, Digestive Diseases Division
Bethesda, Maryland
EMPLOYEE DATA
23. Veterans Preference
17. Occ.
Code
1- None
3- 10-Point/Disability
2- 5-Point 4- 10-Point/Compensable
USUHS, Hebert School of Medicine
Department of Medicine, Nephrology Division
Bethesda, Maryland
5- 10-Point/Other
6- 10-Point/Compensable/30%
24. Tenure
25. Agency Use
26. Veterans Pref for RIF
0- None
2- Conditional
1- Permanent 3- Indefinite
YES
27. FEGLI
30. Retirement Plan
31. Service Comp. Date (leave)
28. Annuitant Indicator
29. Pay Rate Determinant
32. Work Schedule
33. Part-Time Hours Per
Biweekly
Pay Period
F
POSITION DATA
34. Position Occupied
35. FLSA Category
1- Competitive Service
2- Excepted Service
1
3- SES General
4- SES Career
38. Duty Station Code
NO
36. Appropriation Code
37. Bargaining Unity Status
E- Exempt
N- Nonexempt
39. Duty Station (City – Count – State or Overseas Location)
40. Agency
41.
45. Educational Level
46. Year Degree Attained
DDAAFD
42.
43.
44.
1BICDG
1BICDG
47. Academic Discipline
48. Functional Class
49. Citizenship
1- USA
50. Veterans Status
51. Supervisory Status
8 - Other
PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function
Initials/Signature
Date
Office/Function
A.
D.
B.
E.
C.
F.
2. Approval: I certify that the information entered on this form is accurate and that the
proposed action is in compliance with statutory and regulatory requirements.
Signature
CONTINUED ON REVERSE SIDE
52-118
OVER
Initials/Signature
Date
Approval Date
Editions Prior to 7/91 Are Not Usable After 6/30/93
NSN 7540-01-333-6239
Sample RPA for GS/FWS Reassignment Actions
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement?
If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
PART E – Employee Resignation/Retirement
YES
NO
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding
address. Your reason may be considered in any future decision regarding your re-employment in the
Federal service and may also be used to determine your eligibility for umemployment compensation
benefits. Your forwarding address will be used primarily to mail you copies of any documents you
should have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code.
Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and
their records, while section 8506 requires agencies to furnish the specific reason for termination of
Federal service to the Secretary of Labor or a State agency in connection with administration of
unemployment compensation programs.
The furnishing of the information is voluntary; however, failure to provide it my result in your not
receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you;
and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at
the end of the day – midnight – unless you specify otherwise.)
2. Effective Date
3. Your Signature
PART F – Remarks for SF 50
4. Date Signed
5. Forwarding Address (Number, Street, City, State, ZIP Code)
Sample RPA for GS/FWS Career-Ladder Promotion
Standard Form 52
Rev. 7/91
U.S. Office of Personnel Management
FPM Supp. 296-33, Subch. 3
REQUEST FOR PERSONNEL ACTION
PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
2. Actions Requested
Career-Ladder Promotion
MED-11-001
3. For Additional Information Call (Name and Telephone Number)
4. Proposed Effective Date
JOHN DOE, (301) 295-1234
1 June 2011
5. Action Requested By (Typed Name, Title, Signature, and Request Date)
6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Immediate Supervisor, DVM, Director, MED & Date
Authorizing Official, Chair Person, DVM, MED & Date
PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
3. Date of Birth
4. Effective Date
Doe, Jane
FIRST ACTION
SECOND ACTION
5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
15. TO: Position Title and Number
Security Assistant (OA)
PD# F444B
8. Pay Plan
9. Occ. Plan
10. Grade or Level
GS
080
09
12A. Basic Pay
Security Assistant (OA)
PD# F444A
11. Step or Rate
12. Total Salary
13. Pay Basis
16. Pay
Plan
GS
12B. Locality Adj.
12C. Adj. Basic Pay
12D. Other Pay
18. Grade or Level
19. Step or Rate
20. Total Salary
11
080
20A. Basic Pay
14. Name and Location of Position’s Organization
20B. Locality Adj.
20C. Adj. Basic Pay
21. Pay
Basis
20D. Other Pay
22. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine
Department of Medicine, Nephrology Division
Bethesda, Maryland
EMPLOYEE DATA
23. Veterans Preference
17. Occ.
Code
1- None
3- 10-Point/Disability
2- 5-Point 4- 10-Point/Compensable
USUHS, Hebert School of Medicine
Department of Medicine, Nephrology Division
Bethesda, Maryland
5- 10-Point/Other
6- 10-Point/Compensable/30%
24. Tenure
25. Agency Use
26. Veterans Pref for RIF
0- None
2- Conditional
1- Permanent 3- Indefinite
YES
27. FEGLI
30. Retirement Plan
31. Service Comp. Date (leave)
28. Annuitant Indicator
29. Pay Rate Determinant
32. Work Schedule
33. Part-Time Hours Per
Biweekly
Pay Period
F
POSITION DATA
34. Position Occupied
35. FLSA Category
1- Competitive Service
2- Excepted Service
1
3- SES General
4- SES Career
38. Duty Station Code
NO
36. Appropriation Code
37. Bargaining Unity Status
E- Exempt
N- Nonexempt
39. Duty Station (City – Count – State or Overseas Location)
40. Agency
41.
45. Educational Level
46. Year Degree Attained
DDAAFD
42.
43.
44.
1BICDG
1BICDG
47. Academic Discipline
48. Functional Class
49. Citizenship
1- USA
50. Veterans Status
51. Supervisory Status
8 - Other
PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function
Initials/Signature
Date
Office/Function
A.
D.
B.
E.
C.
F.
2. Approval: I certify that the information entered on this form is accurate and that the
proposed action is in compliance with statutory and regulatory requirements.
Signature
CONTINUED ON REVERSE SIDE
52-118
OVER
Initials/Signature
Date
Approval Date
Editions Prior to 7/91 Are Not Usable After 6/30/93
NSN 7540-01-333-6239
Sample RPA for GS/FWS Career-Ladder Promotion
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement?
If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
PART E – Employee Resignation/Retirement
YES
NO
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding
address. Your reason may be considered in any future decision regarding your re-employment in the
Federal service and may also be used to determine your eligibility for umemployment compensation
benefits. Your forwarding address will be used primarily to mail you copies of any documents you
should have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code.
Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and
their records, while section 8506 requires agencies to furnish the specific reason for termination of
Federal service to the Secretary of Labor or a State agency in connection with administration of
unemployment compensation programs.
The furnishing of the information is voluntary; however, failure to provide it my result in your not
receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you;
and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at
the end of the day – midnight – unless you specify otherwise.)
2. Effective Date
3. Your Signature
PART F – Remarks for SF 50
4. Date Signed
5. Forwarding Address (Number, Street, City, State, ZIP Code)
Sample RPA for AD Recruitment Actions
Standard Form 52
Rev. 7/91
U.S. Office of Personnel Management
FPM Supp. 296-33, Subch. 3
REQUEST FOR PERSONNEL ACTION
PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
2. Actions Requested
Recruit/Fill - New or Vice (if vice include employee’s) (tenure track or non-tenured track)
SUR-12-001
3. For Additional Information Call (Name and Telephone Number)
4. Proposed Effective Date
ASAP
Jane Doe (301) 295-1234
5. Action Requested By (Typed Name, Title, Signature, and Request Date)
6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
John Doe, Chair, Department of Surgery
Jim Doe, Dean, School of Medicine
PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
FIRST ACTION
SECOND ACTION
5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
3. Date of Birth
4. Effective Date
15. TO: Position Title and Number
Associate Professor
PD #1234
8. Pay Plan
9. Occ. Plan
12A. Basic Pay
10. Grade or Level
11. Step or Rate
12B. Locality Adj.
12. Total Salary
12C. Adj. Basic Pay
13. Pay Basis
12D. Other Pay
16. Pay
Plan
17. Occ.
Code
AD
602
20A. Basic Pay
14. Name and Location of Position’s Organization
18. Grade or Level
19. Step or Rate
00
00
20B. Locality Adj.
20. Total Salary
21. Pay
Basis
PA
20C. Adj. Basic Pay
20D. Other Pay
22. Name and Location of Position’s Organization
USUHS, School of Medicine
Department of Surgery, Cardiology Division
Bethesda, MD
EMPLOYEE DATA
23. Veterans Preference
1- None
3- 10-Point/Disability
2- 5-Point 4- 10-Point/Compensable
5- 10-Point/Other
6- 10-Point/Compensable/30%
25. Agency Use
24. Tenure
26. Veterans Pref for RIF
0- None
2- Conditional
1- Permanent 3- Indefinite
YES
27. FEGLI
30. Retirement Plan
31. Service Comp. Date (leave)
29. Pay Rate Determinant
32. Work Schedule
33. Part-Time Hours Per
Biweekly
Pay Period
F
POSITION DATA
34. Position Occupied
35. FLSA Category
1- Competitive Service
2- Excepted Service
2
3- SES General
4- SES Career
38. Duty Station Code
NO
28. Annuitant Indicator
36. Appropriation Code
37. Bargaining Unity Status
E- Exempt
N- Nonexempt
39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD
40. Agency
45. Educational Level
41.
42.
43.
DDAAFD
1BICDG
1BICDG
44.
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship
1- USA
50. Veterans Status
51. Supervisory Status
8 - Other
PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function
Initials/Signature
Date
Office/Function
A.
D.
B.
E.
C.
F.
pproval: I certify that the information entered on this form is accurate and that the
proposed action is in compliance with statutory and regulatory requirements.
Signature
CONTINUED ON REVERSE SIDE
52-118
OVER
Initials/Signature
Date
Approval Date
Editions Prior to 7/91 Are Not Usable After 6/30/93
NSN 7540-01-333-6239
Sample RPA for AD Recruitment Actions
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement?
If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
PART E – Employee Resignation/Retirement
YES
NO
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding
address. Your reason may be considered in any future decision regarding your re-employment in the
Federal service and may also be used to determine your eligibility for umemployment compensation
benefits. Your forwarding address will be used primarily to mail you copies of any documents you
should have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code.
Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and
their records, while section 8506 requires agencies to furnish the specific reason for termination of
Federal service to the Secretary of Labor or a State agency in connection with administration of
unemployment compensation programs.
The furnishing of the information is voluntary; however, failure to provide it my result in your not
receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you;
and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at
the end of the day – midnight – unless you specify otherwise.)
2. Effective Date
3. Your Signature
PART F – Remarks for SF 50
4. Date Signed
5. Forwarding Address (Number, Street, City, State, ZIP Code)
Sample RPA for Hiring Volunteers
Standard Form 52
Rev. 7/91
U.S. Office of Personnel Management
FPM Supp. 296-33, Subch. 3
REQUEST FOR PERSONNEL ACTION
PART A – Request Office (Also complete Part B, Items 1, 7-22, 32, 33, 36, and 39.)
1. Actions Requested
2. Actions Requested
Volunteer NTE 12/23/2012
3. For Additional Information Call (Name and Telephone Number)
4. Proposed Effective Date
Point of Contact
16-JUL-2012
5. Action Requested By (Typed Name, Title, Signature, and Request Date)
6. Action Authorized by (Typed Name, Title, Signature, and Concurrence Date)
Supervisor or Department Head
Next higher level official
PART B – For Preparation of SF 50 (Use only codes in FPM Supplement 292-1. Show all dates in month-day-year order.)
1. Name (Last, First, Middle)
2. Social Security Number
3. Date of Birth
Doe, John
000-00-0000
00/00/0000
FIRST ACTION
SECOND ACTION
5-A. Code
5-B. Nature of Action
6-A. Code
6-B. Nature of Action
5-C. Code
5-D. Legal Authority
6-C. Code
6-D. Nature of Action
5-E. Code
5-F. Legal Authority
6-E. Code
6-F. Nature of Action
7. FROM: Position Title and Number
4. Effective Date
15. TO: Position Title and Number
VOLUNTEER
8. Pay Plan
9. Occ. Plan
12A. Basic Pay
10. Grade or Level
11. Step or Rate
12B. Locality Adj.
12. Total Salary
12C. Adj. Basic Pay
13. Pay Basis
16. Pay
Plan
12D. Other Pay
17. Occ.
Code
18. Grade or Level
20. Total Salary
0.00
20A. Basic Pay
14. Name and Location of Position’s Organization
19. Step or Rate
20B. Locality Adj.
20C. Adj. Basic Pay
21. Pay
Basis
20D. Other Pay
22. Name and Location of Position’s Organization
USUHS, Hebert School of Medicine
Department Name
EMPLOYEE DATA
23. Veterans Preference
1- None
3- 10-Point/Disability
2- 5-Point 4- 10-Point/Compensable
5- 10-Point/Other
6- 10-Point/Compensable/30%
24. Tenure
25. Agency Use
26. Veterans Pref for RIF
0- None
2- Conditional
1- Permanent 3- Indefinite
YES
27. FEGLI
30. Retirement Plan
31. Service Comp. Date (leave)
NO
28. Annuitant Indicator
29. Pay Rate Determinant
32. Work Schedule
33. Part-Time Hours Per
Biweekly
Pay Period
POSITION DATA
34. Position Occupied
35. FLSA Category
1- Competitive Service
2- Excepted Service
3- SES General
4- SES Career
38. Duty Station Code
36. Appropriation Code
37. Bargaining Unity Status
E- Exempt
N- Nonexempt
39. Duty Station (City – Count – State or Overseas Location)
Bethesda, MD
40. Agency
41.
42.
43.
44.
45. Educational Level
46. Year Degree Attained
47. Academic Discipline
48. Functional Class
49. Citizenship
1- USA
50. Veterans Status
51. Supervisory Status
8 - Other
PART C – Reviews and Approvals (Not to be used by requesting office.)
1. Office/Function
Initials/Signature
Date
Office/Function
A.
D.
B.
E.
C.
F.
2. Approval: I certify that the information entered on this form is accurate and that the
proposed action is in compliance with statutory and regulatory requirements.
Signature
CONTINUED ON REVERSE SIDE
52-118
OVER
Initials/Signature
Date
Approval Date
Editions Prior to 7/91 Are Not Usable After 6/30/93
NSN 7540-01-333-6239
Sample RPA for Hiring Volunteers
PART D – Remarks by Requesting Office
(Note to Supervisors: Do you know of additional or conflicting reasons for the employee’s resignation/retirement?
If “Yes”, please state these facts on a separate sheet and attach to SF 52.)
PART E – Employee Resignation/Retirement
YES
NO
Privacy Act Statement
You are requested to furnish a specific reason for your resignation or retirement and a forwarding
address. Your reason may be considered in any future decision regarding your re-employment in the
Federal service and may also be used to determine your eligibility for umemployment compensation
benefits. Your forwarding address will be used primarily to mail you copies of any documents you
should have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301, 3301, and 8506 of title 5, U.S. Code.
Sections 301 and 3301 authorize OPM
and agencies to issue regulations with regard to employment of individuals in the Federal service and
their records, while section 8506 requires agencies to furnish the specific reason for termination of
Federal service to the Secretary of Labor or a State agency in connection with administration of
unemployment compensation programs.
The furnishing of the information is voluntary; however, failure to provide it my result in your not
receiving: (1) your copies of those documents you should have; (2) pay or other compensation due you;
and (3) any unemployment compensation benefits to which you may be entitled.
1. Reasons for Resignation/Retirement (NOTE: Your reasons are used in determining possible unemployment benefits. Please be specific and avoid generalizations. Your resignation/retirement is effective at
the end of the day – midnight – unless you specify otherwise.)
2. Effective Date
3. Your Signature
PART F – Remarks for SF 50
4. Date Signed
5. Forwarding Address (Number, Street, City, State, ZIP Code)
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UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Instructions for Completing a Request
for Personnel Action (SF-52)
Part A
Block #1. Action Requested - Type in the Action that you are requesting, e.g., Establish
(Classify), Recruit, Reassignment, Realignment, Extension of Appointment, Resignation, LeaveWithout-Pay, Name Change, etc.
Block #2. Request Number - Each Department/Activity should assign a department Log Number
to monitor/track each SF-52 submitted by the department /activity. For example - MED-11-001
(this represents the three letter department code, the fiscal year, and the number of action). Once
the request is coordinated through appropriate departments and the FMG, the CHR will assign a
request for personnel action (RPA) number to your SF-52 using the DCPDS system.
Block #3. For Additional Information Call - Enter the name and telephone number of the
Administrative Point of Contact, which would be the person who can furnish additional
information, if required.
Block #4. Proposed Effective Date - Enter the date the requesting office wants the action
completed or annotate ASAP.
Block #5. Action Requested By - Enter the name, title, signature, and date of the person
requesting the action. Normally, this will be the immediate supervisor.
Block #6. Action Authorized by - Enter the name, title, signature, and date of the person
authorizing the action. This will be the appropriate Chairperson, the Department/Activity Head,
or higher level official in the chain of command.
Part B
Block #15. Enter Position Title and PD Description Number if applicable.
Block #16. Enter Pay Plan, e.g. AD, GS, WG, WL, etc.
Block #17. Enter Occupational Code (position series), e.g. 0201, 0602, 0510, etc.
Block #18. Enter Grade or Level, (5/6/7) etc. If the position is new, leave blank. The block will
be completed by the CHR/HRSC. If the position is an AD position, it will be 00.
Block #22. Enter the name and location of the position’s organization.
Block #32. Enter the designated work schedule (i.e., F for full-time and P for part-time. If the
position is part-time, enter the tour duty in Part D - Remarks by Requesting Official of the SF-52).
13 April 2012
Page 1
Instructions for Completing a Request for Personnel Action (SF-52)
Block #34. Enter the service the position falls under (i.e., competitive, excepted, etc).
Block #41. Enter the UIC#. USUHS UIC # is DDAAFD.
Block #42. Enter the Org Code (if known or leave blank), e.g. 1BICDG
Block #43. Enter the Cost Code Center (if known), same number as your Org Code.
*Note: Once the request is coordinated through appropriate departments and the FMG, the
request will be submitted to the CHR and a request for personnel action (RPA) number will be
assigned to your RPA using the DCPDS system.
13 April 2012
Page 2
1. Agency Position
No.
POSITION DESCRIPTION (Please Read Instructions on the Back)
2.
3.
Reason for Submission
Redescription
Reestablishment
New
Other
4. Employing Office Location
Service
Hdqtrs.
Field
6. OPM Certification No.
8. Financial Statements Required
9. Subject to IA
Action
Bethesda, Maryland
7. Fair Labor Standards Act
Explanation (Show any positions replaced)
Exempt
Executive Personnel
Employment and
Financial Disclosure
Financial Interests
11. Position Is:
12. Sensitivity
Nonexempt
10. Position Status
Competitive
Supervisory
Excepted (Specify in Remarks)
Managerial
SES (Gen.)
Neither
SES (CR)
Official Title of Position
15. Classified/Graded by
5. Duty Station
Pay Plan
Yes
1-NonSensitive
3-Critical
Sensitive
2-Noncritical
Sensitive
4-Special
Sensitive
Occupational Code
Grade
No
13. Competitive Level
Code
14. Agency Use
Date
Initials
a. U.S. Office of Personnel
Management
b. Department, Agency or
Establishment
c. Second Level Review
d. First Level Review
e. Recommended by
Supervisor or
Initiating Office
Position Title as applicable (Assistant Professor/Program
Specialist/Supply Technician)
16. Organizational Title of Position (if different from official title)
18. Department, Agency, or Establishment
AD/GS/
9 or 00
301
WG
for AD)
17. Name of Employee (if vacant, specify)
c. Third Subdivision
Cardiology Division
DoD, Uniformed Services University of the Health Sciences
a. First Subdivision
School of Medicine
b. Second Subdivision
Department of Surgery
d. Fourth Subdivision
19. Employee Review - This is an accurate description of the major
duties and responsibilities of my position.
Signature of Employee (optional)
e. Fifth Subdivision
20. Supervisory Certification. I certify that this is an accurate
statement of the major duties and responsibilities of this position
and its organizational relationships, and that the position is
necessary to carry out Government functions for which I am
responsible. This certification is made with the knowledge that
a. Typed Name and Title of Immediate Supervisor
b. Typed Name and Title of Higher-Level Supervisor or Manager (optional)
Signature
Signature
Date
this information is to be used for statutory purposes relating to
appointment and payment of public funds, and that false or
misleading statements may constitute violations of such statutes or
their implementing regulations.
Date
ELECTRONICALLY SIGNED //S//
ELECTRONICALLY SIGNED //S//
21. Classification/Job Grading Certification. I certify that this position has been
classified/graded as required by Title 5, U.S. Code, in conformance with
standards published by the U.S. Office of Personnel Management or, if no
published standards apply directly, consistently with most applicable published
standards.
22. Position Classification Standards Used in Classifying/Grading Position
Typed Name and Title of Official Taking Action
Signature
ELECTRONICALLY SIGNED
23.
a.
b.
c.
24.
Position Review
Employee (optional)
Supervisor
Classifier
Remarks
Initials
3/29/01
Date
Initials
Date
Information for Employees. The standards, and information on their application, are available in the
personnel office. The classification of the position may be reviewed and corrected by the agency or the
U.S. Office of Personnel Management. Information on classification/job grading appeals, and complaints
on exemption from FLSA, is available from the personnel office or the U.S. Office of Personnel
Management.
Initials
Date
Initials
25. Description of Major Duties and Responsibilities (See Attached)
NSN 7540-00-634-4265
Previous Edition Usable
5008-106
Date
Initials
Date
OF 8 (Rev. 1-85)
U.S. Office of Personnel Management
FPM Chapter 295
Optional Form 8 (BACK)
(Revised 1/85)
Instructions for Completing Optional Form 8
POSITION DESCRIPTION
In order to comply with the requirements of FPM Chapter 295, subchapter
3, and other provisions of the FPM, agencies must complete the items
marked by an asterisk. Agencies may determine what other items are to
be used.
14. Agencies may use this block for any additional coding
requirement.
3. Check one.
*15. Enter classification/job grading action.
•
For "Official Title of Position," see the applicable classification or
job grading standard. For positions not covered by a published
standard, see the General Introduction to "Position Classification
Standards," Section III, for GS positions, or FPM Supplement
512-1, "Job Grading System for Trades and Labor Occupations,"
Part 1, Section III.
•
For "Pay Plan" code, see FPM Supplement 292-1, "Personnel
Data Standards," Book III.
•
For "Occupational Code," see the applicable standard; or, where
no standard has been published, see the "Handbook of
Occupational Groups and Series of Classes" for GS positions, or
FPM Supplement 512-1, Part 3, for trades and labor positions.
For all positions in scientific and engineering occupations,
enter the two-digit functional classification code in
parentheses immediately following the occupational code,
e.g., "GS-1310(14)." The codes are listed and discussed in the
General Introduction to "Position Classification Standards,"
Section VI.
*4. Enter geographical location by city and State (or if position is in a
foreign country, by city and country).
16. Enter the organizational, functional, or working title if it differs from
the official title.
*5. Enter geographical location if different from that of #4.
17. Enter the name of the incumbent. If there is no incumbent, enter
"vacancy."
*1. Enter position number used by the agency for control purposes.
See FPM Chapter 312, Subchapter 3.
*2. Check one.
•
"Redescription" means the duties and/or responsibilities of an
existing position are being changed.
•
"New" means the position has not previously existed.
•
"Reestablishment" means the position previously existed, but
had been cancelled.
•
"Other" covers such things as change in title or occupational
series without a change in duties or responsibilities.
•
The "Explanation" section should be used to show the
reason if "Other" is checked, as well as any position(s)
replaced by position number, title, pay plan, occupational
code, and grade.
6. To be completed by OPM when certifying positions. (See Item 15
for date of OPM certification.) For SES and GS-16/18 positions and
equivalent, show the position number used on OPM Form 1390
(e.g., DAES0012).
*7. Check one to show whether the incumbent is exempt or non-exempt
from the minimum wage and overtime provisions of the Fair Labor
Standards Act. See FPM Chapter 551.
8. Check box if statement is required. See FPM Chapter 734 for the
Executive Personnel Financial Disclosure Report, SF 278. See
FPM Chapter 735, Subchapter 4, for the Employment and Financial
interests Statement.
9. Check one to show whether Identical Additional positions are
permitted. See FPM Chapter 312, Subchapter 4. Agencies may
show the number of such positions authorized and/or established
after the "Yes" block.
10. Check one. See FPM Chapter 212 for information on the competitive
service and FPM Chapter 213 for the excepted service. For a
position in the excepted service, enter authority for the exception,
e.g., "Schedule A-213.3102(d)" for Attorney positions excepted
under Schedule A of the Civil Service Regulations. SES (Gen)
stands for a General position in the Senior Executive Service, and
SES (CR) stands for a Career Reserved position.
11. Check one.
•
•
A "Supervisory" position is one that meets the requirements for
a supervisory title as set forth in current OPM classification and
job-grading guidance. Agencies may designate first-level
supervisory positions by placing "1" or "1st" after "Supervisory."
A "Managerial" position is one that meets the requirements for
such a designation as set forth in current OPM classification
guidance.
12. Check one to show whether the position is non-sensitive, non-critical
sensitive, critical sensitive, or special sensitive for security purposes.
If this is an ADP position, write the letter "C" beside the sensitivity.
13. Enter competitive level code for use in reduction-in-force actions.
See FPM Chapter 351.
*18. Enter the organizational location of the position, starting with the
name of the department or agency and working down from there.
19. If the position is occupied, have the incumbent read the attached
description of duties and responsibilities.
The employee's
signature is optional.
*20. This statement normally should be certified by the immediate
supervisor of the position. At its option, an agency may also
have a higher-level supervisor or manager certify the statement.
*21. This statement should be certified by the agency official who
makes the classification/job grading decision. Depending on
agency regulations, this official may be a personnel office
representative, or a manager or supervisor delegated
classification/job grading authority.
22. Enter the position classification/job grading standard(s) used and
the date of issuance, e.g., "Mail and File, GS-305, May 1977."
23. Agencies are encouraged to review periodically each established
position to determine whether the position is still necessary and,
if so, whether the position description is adequate and
classification/job grading is proper. See FPM Letter 536-1 (to be
incorporated into FPM Chapter 536). This section may be used
as part of the review process. The employee's initials are
optional. The initials by the supervisor and classifier represent
recertifications of the statements in items #20 and #21
respectively.
24. This section may be used by the agency for additional coding
requirements or for any appropriate remarks.
*25. Type the description on plain bond paper and attach to the form.
The agency position number should be shown on the attachment.
See appropriate instructions for format of the description and for
any requirements for evaluation documentation, e.g.,
"Instructions for the Factor Evaluation System," in the General
Introduction to "Position Classification Standards," Section VII.
UNIFORMED SERVICES UNIVERSITY
of the Health Sciences, Civilian Human Resources
Recruitment Checklist
Recruitment Checklist
Please provide the information below with your Recruitment Request for Personnel Action (RPA). This
information identifies key elements that are essential to proceed with your recruitment action.
POSITION TO BE FILLED
Title, PP/Ser/Gr
RPA#
PD #
Vice (Employee Name)
POINT OF CONTACT INFORMATION
Supervisor’s Name
POC/AO
SME
Position Data
Other
Recruitment
Information
Phone
Phone
Phone
Target PP, Ser, Grade
PD Attached to RPA (Yes or N/A)
Is PD Accurate? (Yes or No)
NTE Date (i.e. 120 days, 1 year, 366 days, etc.)
Physical Exam Required (Yes or No)
Drug testing Required (Yes or No)
Certification or Licensing Required? (Yes or No)
Email
Email
Email
If yes, what type?
Recruit at Grade Level(s):
Number of Vacancies
PCS Authorized (Yes or No)
Recruitment Incentives (Yes or No)
Duration of Announcement (Minimum 5 days)
IDENTIFY THOSE RECRUITMENT SOURCES YOU WOULD LIKE TO UTILIZE TO FILL YOUR VACANCY.
Area of
Consideration
DE –U.S. Citizen
VRA and Veterans with 30% or more Disability
Current Federal (Includes VEOA Eligible)
Current Department of Defense (DOD)
Reinstatement Eligible
Military Spouses (E.O. 13473, E.O. 12721)
USUHS Only (Current Career/Career-Conditional Employees)
Re-employed Annuitants
Individuals with Disabilities (Schedule A)
Student Educational Employment Program
Wounded Warriors
VEOA
IDENTIFY 3-5 MAJOR DUTIES AND THE CORRESPONDING COMPETENCIES (Knowledge, skills and abilities) WHICH SUPPORT
THESE DUTIES.
1.
All duties and
competencies must
be supported in the
position description.
2.
3.
4.
5.
13 April 2012
UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES
Civilian Human Resources Office
4301 JONES BRIDGE ROAD
BETHESDA, MARYLAND 20814-4799
Date
MEMORANDUM FOR HUMAN RESOURCES ACTIONS COMMITTEE
THROUGH:
SUBJECT: Justification - Establish and Recruit/Fill for ____________________
The justification memorandum shall address the following:
1. Reason/Rationale
2. Requirement/Need
3. Impact on mission
4. Fund Explanation
VOLUNTEER AGREEMENT FOR
APPROPRIATED FUND ACTIVITIES
NONAPPROPRIATED FUND INSTRUMENTALITIES
PRIVACY ACT STATEMENT
AUTHORITY: Section 1588 of Title 10, U.S. Code, and E.O. 9397.
PRINCIPAL PURPOSE(S): To document voluntary services provided by an individual, including the hours of service performed, and to
obtain agreement from the volunteer on the conditions for accepting the performance of voluntary service.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however failure to complete the form may result in an inability to accept voluntary services or an inability to
document the type of voluntary services and hours performed.
PART I - GENERAL INFORMATION
1. TYPED NAME OF VOLUNTEER (Last, First, Middle Initial)
2. SSN
3. DATE OF BIRTH (YYYYMMDD)
4. INSTALLATION
5. ORGANIZATION/UNIT WHERE SERVICE OCCURS
6. PROGRAM WHERE SERVICE OCCURS
7. ANTICIPATED DAYS OF WEEK
8. ANTICIPATED HOURS
9. DESCRIPTION OF VOLUNTEER SERVICES
PART II - VOLUNTEER IN APPROPRIATED FUND ACTIVITIES
10. CERTIFICATION
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States
Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the
performance of approved volunteer services, tort claims, the Privacy Act, criminal conflicts of interest, and defense of certain suits arising
out of legal malpractice. I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits
for these voluntary services. I agree to be bound by the laws and regulations applicable to voluntary service providers and agree to
participate in any training required by the installation or unit in order for me to perform the voluntary services that I am offering. I agree to
follow all rules and procedures of the installation or unit that apply to the voluntary services I will be providing.
b. DATE SIGNED (YYYYMMDD)
a. SIGNATURE OF VOLUNTEER
11.a. TYPED NAME OF ACCEPTING OFFICIAL
c. DATE SIGNED (YYYYMMDD)
b. SIGNATURE
(Last, First, Middle Initial)
PART III - VOLUNTEER IN NONAPPROPRIATED FUND INSTRUMENTALITIES
12. CERTIFICATION
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States
Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the
performance of approved volunteer services and liability for tort claims as specified in 10 U.S.C. Section 1588(d)(2). I expressly agree
that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be
bound by the laws and regulations applicable to voluntary service providers, and agree to participate in any training required by the
installation or unit in order for me to perform the voluntary services that I am offering. I agree to follow all rules and procedures of the
installation or unit that apply to the voluntary services that I am offering.
b. DATE SIGNED (YYYYMMDD)
a. SIGNATURE OF VOLUNTEER
13.a. TYPED NAME OF ACCEPTING OFFICIAL
c. DATE SIGNED (YYYYMMDD)
b. SIGNATURE
(Last, First, Middle Initial)
PART IV - TO BE COMPLETED AT END OF VOLUNTEER'S SERVICE BY VOLUNTEER SUPERVISOR
14. AMOUNT OF VOLUNTEER TIME DONATED
a. YEARS (2,087
hours=1 year)
b. WEEKS c. DAYS
17.a. TYPED NAME OF SUPERVISOR
15. SIGNATURE
16. TERMINATION DATE
(YYYYMMDD)
d. HOURS
c. DATE SIGNED (YYYYMMDD)
b. SIGNATURE
(Last, First, Middle Initial)
DD FORM 2793, FEB 2002
PREVIOUS EDITION IS OBSOLETE.
Reset
Exception to Standard Form 50 granted by
Office of Personnel Management (OPM) waiver.