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ATTACHMENT #1NAVMED P-117, CHANGE 107U.S. NavyManual of the Medical DepartmentNAVMED P-11729 October 1992Department of the NavyNAVMED P-117CHANGE 107Subj: Off-duty Remunerative Professional Employment (Regulatory)1. General. Off-duty remunerative professional civilian employment, including self-employment (hereto referred toas off duty employment) of active duty Medical Department officers is subject to policies herein stated by the chief,Bureau of Medicine and Surgery, and policies applicable to all members of the naval service as stated by theSecretary of the Navy (SECNAVINST 5370.2 series) and the Chief of Naval Personnel (BUPERSMAN 34205000).No Medical Department officers on active duty shall engage in any off-duty employment without first obtaining thepermission of the commanding officer.2. Guidelinea. Medical Department officers on active duty are in a 24-hour duty status and their military duty takesprecedence on their time, talents, and attention.b. Permission for an officer to engage in off-duty employment shall be based on a determination by thecommanding officer that the permission requested is consistent with these guidelines and that the proposedemployment will not interfere with the officer’s military duties. If approved, employment will normally not exceed16 hours per week. Periods in excess of 16 hours per week can be authorized only if the commanding officer findsthat special circumstances exist which indicate that no conflict with military duties will occur, notwithstanding theaddition hours. Permission to engage in off-duty employment maybe withdrawn at any time.c. A Medical Department officer in off-duty employment shall not assume primary responsibility of the care ofany critically ill person on a continuing basis as this will inevitably result in compromise of responsibilities to thepatient or the primacy of military obligations.d. Medical Department officer trainees are prohibited from off-duty employment. Other Medical DepartmentOfficers a re discouraged from off-duty employment. No officer shall request or be granted administrative absencefor the primary purpose of conducting off-duty employment.e. Off-duty employment shall not be conducted on military premises, involve expense to the Federal government,nor involve use of military equipment, personnel, or supplies. Military personnel may not be employed by MedicalDepartment officers involved in off-duty employment.f. Off-duty employment shall not interfere, nor be in competition, with local civilian practitioners in the healthprofessions and must be carried out in compliance with all applicable licensing requirements. To ensure this, astatement shall be provided form the appropriate local professional association indicating that there is a need for theindividual’s service in the community. Local licensing requirements are the responsibility of officers wishing toengage in private practice. Those engaging in private practice are subject to all requirements of the Federal Narcoticlaw, including registration and payment of tax.g. There may be no self-referral from the military setting to their off-duty employment on the part of militaryMedical Department officer.h. No Medical Department office on active duty in off-duty employment may solicit or accept a fee directly orindirectly for the care of member, retired member, or dependent of such members of the uniformed services as are
entitled to medical or dental care by those services. Indirect acceptance shall be interpreted to include those feescollected by an emergency room or walk-in clinic staffed by military medical officer. Entitled members must bescreened and identified as such by the facility and their charges reduced to reflect that portion of the charges whichare accounted for by the military medical office’s services. Nor may such a fee be accepted directly or indirectly forthe care of Department of Veterans Affairs beneficiaries.i. The Assistant Secretary of Defense (Health Affairs) has decreed that it will be presumed that a conflict ofinterest exists and hence, CHAMPUS payments will be disallowed in any claim of a CHAMPUS provider whoemploys an active duty military member or civilian employee. The only two exceptions are:(1) Indirect payments to private organizations to which physicians of the National Health Service Corps(NHSC) are assigned (but direct payments to the NYSC physician would still be prohibited).(2) Payments to a hospital employing Government medical personnel in an emergency room provided themedical care was not furnished directly by the Government personnel.j. Subsidiary obligations arising out of off-duty employment, such as appearances in court or testimony before acompensation board, which take place during normal working hours, shall be accomplished only while on annualleave.k. These guidelines do not apply to the provision of emergency medical assistance in isolated instances. Alsoexcluded are non-remunerative community services operated by nonprofit organizations for the benefit of all thecommunity and deprived persons, such as a drug abuse program, program volunteer, venereal disease centers, andfamily planning centers.l. Medical Department officers are expected to be aware of and comply with all other status and regulationspertaining to off-duty employment. Where doubt exists as to whether all applicable constraints have beenconsidered, consultation should be effected with the local naval legal service office.3. The local command has primary responsibility of control of off-duty employment by Medical Departmentofficers. Guidelines above serve as a basis for carrying out this responsibility.4. Medical Department officer requesting permission to engage in off-duty employment shall submit their request tothe commanding officer on NAVMED 1610/1, Off-duty Remunerative Professional civilian Employment Request,and shall sign the Statement of Affirmation thereon in the commanding officer’s presence of designee. Approval ordisapproval by the commanding officer shall be indicated in the appropriate section of NAVMED 1610/1. MedicalDepartment officers shall advise their off-duty employers that as military members they are required to respondimmediately to call for military duty that may arise during schedule off-duty employment. The commandingofficer’s approval of an officer’s request for off –duty employment may not be granted without written certificationfrom the off-duty employer that he or she accepts the availability limitations placed on the Medical Departmentofficer.5. The requester shall inform the commanding officer in writing of any deviation in the stated request prior to theinception of any such changes.6. Permission shall be withdrawn at any time by the commanding officer when such employment is determined tobe inconsistent with the above guidelines. Where permission is withdrawn the officer affected shall be afforded andopportunity to submit to the commanding officer a written statement containing the Medical Department officer’sviews or any information pertinent to the discontinuance of the employment.7. Reports are not required to be submitted to BUMED by field activities. However, during Medical and DentalInspectors General visits or other administrative onsite visits, local command compliance with this article will bereviewed. In addition, adequate records should be maintained to provide summarized information as may benecessary for monitoring and evaluating the functioning of this program by BUMED or higher authority.
ATTACHMENT #2HEALTH EXAMINATION AND IMMUNIZATION/SCREENING REQUIREMENT FORMAfter contract award, but prior to performing services, the contract health care worker shall have this formcompleted by a licensed medical practitioner and submitted to NH Yokosuka Materials ManagementDepartment. All health care workers providing services under this contract must meet all the requirementsspecified under the “required documentation” column of this form.*COPIES OF TITER LABORATORY RESULTS MUST BE ATTACHED TO THIS FORMPositive titerDATES and RESULTS(to be completed by examininglicensed practitioner)Hx:Dates of Shots:1.2.Titer/Date:MEASLES/ MUMPS/RUBELLA (MMR)MMR live virus 2-dose vaccine series (only 1 doserequired if born in or before 1957 or if history ofchildhood immunizations is reliable), ORDates of Shots:1.2.Positive titersTiters/Date:HEPATITIS BHBV 3-dose vaccine series AND positive titer, ORDates QUIREDDOCUMENTATIONReliable history of chickenpox disease, OR2-dose vaccine series, ORHBV 3-dose vaccine series with negative titer ANDrepeat 3-dose HBV series with repeat titer AND inthe case of persistent negative titer, counseling bylicensed practitioner regarding implications of nonresponseTetanus/Diphtheria (TD) booster, ORTetanus/Diphtheria/Pertussis (Tdap) within thepreceding 10 years.Two-step Tuberculin Skin Test (TST), OROne Blood Assay for Mycobacterium Tuberculosis(BAMT), ORLATEXAn annual evaluation if known TST reactor,including chest x-ray within 1 year if new hireLatex sensitivity screening questionnaireadministeredIf latex sensitivity suspected, follow withappropriate allergy testingDates of te of TD booster:Date of Tdap:2-Step TST dates:1st test:1st result:2nd test:2nd result:CXR Date:Pos:Neg:Date of evaluation:Results: SensitiveDate of test:Results:BAMT date:Result:Date/result oflast annualeval:Not sensitive[Name of Contract Health Care Worker] has presented for a physical examination.S/he is applying for the position of LICENSED VOCATIONAL PRACTICAL NURSE
He/She was examined on [date] and found to be in good health, meeting the immunization/ screeningrequired above, and is free of any medical condition or infectious disease that may prevent his/her ability to perform services forthe position described above. YESNO [Circle YES or NO]Provider’s Signature: Provider’s Name:Facility/Address:Phone Number: Date:*The facility shall identify any incumbent HCWs who are not required to complete this documentation.
ATTACHMENT #3CITIZENSHIP REQUIREMENTSExcerpt from SECNAV M-5510.30 of June 2006, Appendix F. For a full copy of the Manual 30.pdf.1. All documents submitted as evidence of U. S. citizenship must be certified copies. Uncertified copies are notacceptable. The following documents are acceptable proof of citizenship:a. The original U. S. birth certificate with a raised seal issued at the time of birth from one of the 50 states, oroutlying territories or possessions.b. A hospital birth certification (clinic and commercial birth center certification is not permitted) with anauthenticating raised seal or signature provided all vital information is given.c. A delayed birth certificate provided it shows the birth record was filed within one year after birth, it bears theregistrar's seal and signature, and cites secondary evidence such as a baptismal certificate, certificate of circumcision,affidavits of persons having personal knowledge of the facts of the birth or other official records such as earlycensus, school or insurance.d. U.S. Passport (current or expired) or U.S. passport issued to individual’s parent in which the individual isincluded.e. FS-240 Report of Birth Abroad of a Citizen of the United States of America/Consular Report of Birth.f. FS-545 Certification of Birth issued by a U.S. Consulate or DS-1350 the Department of State Certification.g. INS N-550/570 U.S. Immigration and Naturalization Service Naturalization Certificate.h. INS N-560/561 U.S. Immigration and Naturalization Service Certificate of Citizenship. If the individual does nothave a Certificate of Citizenship, the original Certificate of Naturalization of the parent(s) may be accepted if thenaturalization occurred while the individual was under 18 years of age (or under 16 years of age before 5 October1978) and residing permanently in the U.S.i. Certificate of birth issued by the Canal Zone government indicating U.S citizenship is only acceptable if verifiedby direct government inquiry to: Vital Records Section, Passport Services, 1111 19th Street NW, Suite 510,Washington, D.C. 20522-1705.j. DD 372, Verification of Birth is acceptable for military members (officer and enlisted) provided the birth data islisted and verified by the Department of Vital Statistics.k. DD 1966, Application for Enlistment into the Armed Forces of the United States are acceptable provided thedocuments sighted are listed and attested to by a recruiting official.2. If none of the above forms of evidence are obtainable, a notice from the registrar issued by the state with theindividual’s name, date of birth, which years were searched for a birth record and that there is no birth certificate onfile for the applicant should be presented. *The registrar's notice must be accompanied by the best combination ofthe following secondary evidence:a. Baptismal certificateb. Census recordc. Certificate of circumcision
d. Early school recorde. Family Bible recordf. Doctor’s record of post-natal careg. Newspaper files and insurance papers* NOTE: These documents must be early public records showing the date and place of birth, created within the firstfive years of life. The individual may also submit an Affidavit of Birth, Form DSP-10A, from an older blood relative,i.e., a parent, aunt, uncle, sibling, who has personal knowledge of the birth. It must be notarized or have the sealand signature of the acceptance agent.
ATTACHMENT #4PERSONAL QUALIFICATIONS SHEETPOSITION TITLE: LICENSED VOCATIONAL NURSE1.Every item on this Personal Qualifications Sheet must be addressed. Please sign and date where indicated. Anyadditional information required may be provided on a separate sheet of paper (indicate by number and sectionthe question(s) you are responding to.2.The information you provide will be used to determine your technical acceptability. In addition to this PersonalQualifications Sheet, please submit letters of recommendation as described in Item VIII. of this form.3.After contract award, all of the information you provide will be verified during the credentialing process. At thattime, you will be required to provide the following documentation verifying your qualifications: ProfessionalEducation Degree, Release of Information, Personal and Professional Information Sheet, all medical licensesheld within the preceding 10 years, continuing education certificates, and employment eligibility documentation.If you submit false information, your contract may be terminated for default. This action may initiate thesuspension and debarment process, which could result in the determination that you are no longer eligible forfuture Government contracts.4.Health Certification. Individuals providing services under Government contracts are required to undergo aphysical exam no more than 60 days prior to beginning work. The exam is not required prior to award but isrequired prior to the performance of services under this contract. By signing this form, you have acknowledgedthis requirement.5.Practice Information:YesNoa. Have you ever been the subject of a malpractice claim?*b. Have you ever been a defendant in a felony or misdemeanor case?*c. Has your license or certification to practice ever been revoked or restricted in any state?*d. Have you been hospitalized for any reason during the past 5 years?*e. Are you currently receiving or have you in the past ever received, therapy for any received,therapy for any alcohol related program?*f. Have you ever been unlawfully involved in the use of controlled substance?*g. Are you currently receiving or have you in the past ever received therapy for anyDrug-related condition?*h. Do you currently have or in the past have you ever had an alcohol dependency?**If any of the above is answered "yes" attach a detailed explanation. Specifically address the disposition of the claim orcharges for numbers (a) and (b) above, and the State of the revocation for (c) above.PRIVACY ACT STATEMENTUnder 5 U.S.C. 552a and Executive Order 9397, the information provided on this page and the remainder of the PersonalQualifications Sheet is requested for use in consideration of a contract; disclosure of this information is voluntary; failureto provide this information may result in the denial of the opportunity to enter into a contract.SIGNATUREDate: MM/DD/YYYY
ATTACHMENT #4 (Continued)PERSONAL QUALIFICATIONS SHEETPOSITION TITLE: LICENSED VOCATIONAL NURSEI. GENERAL INFORMATION:NAME (LAST, FIRST, MIDDLE)SSNADDRESSPHONE / FAXE-MAILII. PROFESSIONAL EDUCATIONDEGREE FROM (NAME OF SCHOOL AND LOCATIONDATE OF DEGREE (MM/DD/YYYY)III. PROFESSIONAL LICENSURE (LICENSE MUST BE CURRENT, VALID, AND UNRESTRICTED)STATEDATE OF EXPIRATION (MM/DD/YYYYLICENSE NUMBERIV. APPROVED CONTINUING EDUCATIONTITLE OF COURSEV.COURSE DATESCE HRSBASIC LIFE SUPPORT (Optional) Certification in American Heart Association Basic Life Support (BLS) for
Healthcare Providers; American Heart Association Healthcare Provider Course; American Red Cross CPR (CardioPulmonary Resuscitation) for the Professional Rescuer; or equivalent.TRAINING TYPE LISTED ON CARD:EXPIRATION DATE (MM/DD/YYYY):VI. PROFESSIONAL EMPLOYMENT: List your current and preceding employers. Provide dates as month/year. Ifmore space is required, please use a separate sheet of paper. Identify any medical experience.a.Name and Address of Present EmployerFromToWork performed:b.Name and Address of Present EmployerFromToWork performed:c.Name and Address of Present EmployerFromToWork performed:Are you are currently employed on a Navy contract? Yes NoIf YES, where is your current contract and what is the position?When does the contract expire?VII. ADDITIONAL MEDICAL CERTIFICATION, DEGREES OR LICENSURE: This should include advancededucation such as a Master’s Degree.Type of Certification, Degree or License and Date of Certification or Expiration
VIII. PROFESSIONAL REFERENCESProvide two letters of recommendation from professional peers or supervisors attesting to your clinical andprofessional skills, competencies, patient rapport, training abilities, etc. Reference letters must include name, title,phone number, date of reference, address and signature of the individual providing reference. Reference letters musthave been written within the preceding 5 years.IX. ADDITIONAL MEDICAL CERTIFICATION, DEGREES OR LICENSUREType of Certification, Degree or License and Date of Certification or ExpirationX. ADDITIONAL INFORMATIONProvide any additional information you feel may enhance your ranking, such as your resume, curriculum vitae,commendations or documentation of any awards you may have received, prior military experience, etc.XII. I hereby certify the above information to be true and accurate:SIGNATUREDate: MM/DD/YYYY
ATTACHMENT #5APPLICATION FOR NAVY CONTRACT POSITIONSTHIS IS NOT A CIVIL SERVICE POSITIONI. IMPORTANT INFORMATIONCutoff Date/Time for receipt of applications: 19 MAR 2021/14:00 Japan timeSend applications to:DIRECT SUBMIT (least preferable)Ashore Contract Division (Code 220)Far East Contracting DepartmentU.S. Fleet and Industrial Supply CenterYokosuka, JapanPSC 473, Box 11FPO AP 96349-0011ORE-MAIL TO: Masanori.Rokutan.JA@fe.navy.mil (preferable)A. NOTICE. This position is set aside for individual LICENSED VOCATIONAL NURSE in accordance withDFARS 237.104. Applications from active duty Navy personnel, civilian employees of the Navy, or personscurrently performing medical services under other Navy contracts will not be considered without the prior approvalof the Contracting Officer.B. POSITION SYNOPSIS. The Government is seeking to place under contract a LICENSED VOCATIONALNURSE as required in this solicitation.II. OTHER INFORMATION FOR OFFERORSAfter your application is revie
Washington, D.C. 20522-1705. j. DD 372, Verification of Birth is acceptable for military members (officer and enlisted) provided the birth data is list
