Personnel Action Form – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PHS-1662

Public Health Service

REQUEST FOR PERSONNEL ACTION - COMMISSIONED OFFICER

(5/01)

PHS-1662

(Read instructions on reverse before completing this form.)

1. NAME (LAST, FIRST, MIDDLE INITIAL)

2. PHONE NUMBERS (Include area code)

Work (

)

Home (

)

3A. SSAN

3b. PHS SERIAL NUMBER

3c. CATEGORY

3d. GRADE

T

P

4A. OPDIV / PROGRAM CONTACT

4B. OPDIV / PROGRAM CONTACT PHONE NUMBER

(

)

EXT.

5. TYPE OF ACTION REQUESTED

OTHER

7. DUTY STATIONS

a. FROM (Current Duty Station)

b. TO (New Duty Station)

ADMINISTRATIVE CODE:

BILLET NUMBER / TITLE:

OPDIV / AGENCY / BUREAU:

DIV / BRANCH / SECTION:

MAILSTOP / ROOM NUMBER:

COMPLETE ADDRESS:

(Building, Street,

City, State, ZIP Code)

10.SPECIAL TRAVEL ALLOWANCES OR INSTRUCTIONS

11.NEW ACCOUNTING INFORMATION

12.REMARKS (If applicable, include training preceptor name/phone number)

13.DIVISION AND OPDIV / PROGRAM CLEARANCE AND APPROVAL -- Submission of this form to DCP by the requesting program certifies that all applicable hiring or assignment restrictions and security clearance requirements for this position have been met. (Check as appropriate)

14. APPROVAL (Print or type Name (First - M.I. - Last), Title and Date.)

15. DIVISION OF COMMISSIONED PERSONNEL (DCP) CLEARANCE

Comments, if any:	SIGNATURE OF DCP OFFICIAL	DATE

Created by: PSC Media Arts (301) 443-2454 EF

	PHS-1662	INSTRUCTIONS FOR COMPLETING FORM PHS-1662 (REV. 6/97)
	(5/01)

An additional sheet of plain paper may be added to complete answers, if necessary.

Be sure to put officer’s/applicant’s name and Social Security Number (SSAN) on additional sheets.

See INSTRUCTION 2, Subchapter CC23.6 of the Commissioned Corps Personnel Manual (CCPM), for additional information.

PLEASE TYPE OR PRINT LEGIBLY

After completing this form, forward original to the Division of Commissioned Personnel/HRS/PSC, ATTN: TAS, Room 4-20, 5600 Fishers Lane, Rockville, MD 20857-0001, AT LEAST 20 CALENDAR DAYS BEFORE EFFECTIVE DATE OF REQUESTED ACTION OR 30 CALENDAR DAYS IN THE CASE OF TRAINING. For Calls to Active Duty (CAD) allow additional time, as the 20-day rule does not begin until all of the application materials and the acceptance response have been received in the Division of Commissioned Personnel (DCP).

1.Show the officer’s/applicant’s full name (last name, first name, middle initial) as it appears on official documents.

2.Furnish officer’s duty station/work phone number and applicant’s work and home phone numbers (include area code).

3.Furnish officer’s/applicant’s SSAN, PHS Serial Number (SERNO) (if applicable), Category, and Temporary and Permanent grades (if applicable). Category response should be one of the following:

Medical	Scientist	Dietetics
Dental	Sanitarian	Therapy
Nurse	Veterinary	Health Services
Engineer	Pharmacy

4.Furnish name and phone number of Operating Division (OPDIV)/Program official to be contacted if further information or clarification is necessary.

5.Indicate nature of action requested. See INSTRUCTION 2, Subchapter CC23.6 of the CCPM for definitions of types of actions.

6.Effective date should be the date you want the personnel order to be effective. For orders with travel, this is the day travel begins. Indicate date officer/applicant is to report to his/her new assignment or the last day officer will be at the releasing station. DCP will make adjustments to CAD orders to include time required for travel to initial duty station. [NOTE: Reporting date should not be on a nonwork day such as a holiday or weekend unless the OPDIV/Program specifically wants the officer to report on such a day, and in the case of a CAD the reporting date should not on the 31st of any month.] Show obligation end date and training obligation end date, if applicable. Name and phone number of official concurring in release date must be furnished. If annual leave en route is approved, so indicate and provide actual dates of annual leave.

7.Furnish officer’s current duty station information and "NEW" duty station information. If a CAD order, furnish officer/applicant’s home address in Item 7(a) "Current Duty Station" and furnish "New" duty station information.

8.If temporary duty en route to new permanent duty station is requested, furnish the specific dates and place at which temporary duty will be performed and the purpose of such request.

9.Show mode of travel and the officer’s/applicant’s specific schedule if travel is by means other than privately owned vehicle (POV), e.g., air, train, bus, etc.

10.Indicate whether there are any special travel allowances or instructions about travel expenses, e.g., extra baggage, mixed mode, ferry system, etc.

11.Furnish the Common Accounting Number (CAN) for Pay, Accounting Point (Pay) number, Designated Agent/Timekeeper number, CAN for Travel number, and Accounting Point (Travel/Transportation) number of the office to which the officer will be assigned.

12.Use for any additional necessary remarks.

13.It is mandatory to answer all questions concerning required clearances. Authority for:

Testing Designated Position (TDP): See HHS Personnel Manuel Instruction 792-5 (INTERIM);

Child Care Services (CCS): See 42 USC 13041E; and

Research Officer Group (ROG): See INSTRUCTION 1, Subchapter CC23.6, of the CCPM.

14.Division and OPDIV/Program officials requesting action must sign and date form. If you have any questions, contact your OPDIV / Program Commissioned Corps Liaison.

15. DCP will sign off and issue a personnel order only after all required documentation is furnished.