Phs 50 Form PDF Details

Are you looking to get the most out of your physical fitness goals? One of the best ways to stay on track, measure progress, and identify areas of improvement is by keeping organized records. That’s why it’s important for fitness trainers and athletes alike to understand all about completing a PhS 50 form. This document requires detailed information related to exercise participation, including an individual's strengths and weaknesses, frequency and duration of activities performed over a specified period of time - recording this data can help provide valuable insights into performance improvement. In this post we'll take a look at what makes up a complete PhS50 form, how they are used in the fitness industry, who should be filling them out regularly ,and how staying organized with them can lead to success when trying to reach that next level!

QuestionAnswer
Form NamePhs 50 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesphs 50 form, appointment corps public health service, application commissioned, application commissioned officer

Form Preview Example

OCCO USE ONLY: Date Avail:

 

Cat:

 

Trn Code:

 

Appt Type:

Age:

 

Grad Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

 

OMB No. 0937-0025

 

 

Commissioned Corps of the U.S. Public Health Service

 

 

Expiration: 08/31/2013

APPLICATION FOR APPOINTMENT AS A COMMISSIONED OFFICER IN

THE COMMISSIONED CORPS OF THE U.S. PUBLIC HEALTH SERVICE

BEFORE COMPLETING THE APPLICATION, READ ATTACHED INSTRUCTIONS CAREFULLY. GIVE COMPLETE ANSWERS TO ALL ITEMS.

TYPE OR PRINT IN INK. If additional space is needed, attach an 8 ½ x 11 inch sheet of paper. Include your name, present mailing address, social security number, and the pertinent item numbers on each sheet so used. All material submitted becomes the property of the Federal Government and will not be returned. Part of the information will be used for a suitability/background investigation. YOU MUST SIGN THIS APPLICATION ON PAGE 6 OR YOUR APPLICATION WILL NOT BE PROCESSED. The Commissioned Corps of the U.S. Public Health Service is a Uniformed Service.

Submit signed original and a clearly readable copy (photocopy acceptable) with ORIGINAL SIGNATURE to: Office of Commissioned Corps Operations, 1101 Wootton Parkway, Suite 100, Plaza Level, Rockville, MD 20852. Facsimiles will not be accepted. (If you print, make sure you print legibly.)

1a. FULL NAME (Last, First, Middle)

(Maiden, if any)

2.

SOCIAL SECURITY NUMBER

3a. DATE OF BIRTH (MM/DD/YYYY)

1b. OTHER NAMES USED

From: (MM/YYYY)

Through: (MM/YYYY)

3b. PLACE OF BIRTH (City and State, or Foreign City and Country)

(Continue in Item 35 if needed)

 

 

 

 

 

 

 

 

4.

PROFESSION OR INTENDED PROFESSION (e.g., Chemist, Nurse,

 

 

 

 

Physician)

 

1c. GENDER

MALE

FEMALE

 

 

 

5.CITIZENSHIP (Only United States citizens may be appointed to the Commis- sioned Corps of the U.S. Public Health Service)

NATIVE*

If NATURALIZED (Answer A, B, C, D)

A. Entered: Month

 

 

DAY

 

 

YEAR

 

 

 

B. Naturalized: Month

 

 

DAY

 

 

YEAR

 

C. Naturalization Number:

D. Person to whom number was issued:

Place Naturalized:

* If U.S. citizen born abroad, provide Consulate Report of Birth or other proof of U.S. citizenship.

6.TYPES OF DUTY(IES) FOR WHICH YOU ARE APPLYING (Indicate all that are applicable and appropriate, Dates MM/YYYY)

General Duty (extended Active Duty•Full-time)

Available for Active Duty:

Junior COSTEP (Applicant must

Senior COSTEP (Applicant must

be a full-time student)

be a full-time student)

From:

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

7.CURRENT INFORMATION FOR CONTACTING YOU (YOU MUST NOTIFY THE OFFICE OF COMMISSIONED CORPS OPERATIONS (OCCO) IMME- DIATELY OF ANY CHANGES) Applicant MUST complete the following:

Mail: Contact Name:

Street:

City:

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone (Incl. Area Code): Current: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell: (

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business: (

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-Mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. "PERMANENT" INFORMATION FOR CONTACTING YOU

Mail: Contact Name:

Street:

City:

State:

 

 

 

 

ZIP:

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

 

Telephone (Include Area Code):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ext.

 

 

FAX: (

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any additional information should be listed in Item 35.

9.BASIC EDUCATION AND PROFESSIONAL TRAINING (Include below, all degrees you have earned or training you will have completed by the time you are available for appointment. Foreign medical graduates must submit a copy of ECFMG with application. Official transcripts to include final or latest grading period for all college, graduate, and professional training MUST BE SUBMITTED BEFORE YOU CAN BE APPOINTED .)

COLLEGE, UNIVERSITY, OR OTHER INSTITUTION

List chronologically•latest first

(Include City, State, and ZIP)

DATES ATTENDED

FROM TO

(MM/DD/YYYY) (MM/DD/YYYY)

TOTAL HOURS

CREDIT (Specify) Qtr. or Sem.

 

 

OFFICIAL

DEGREE

DEGREE CON-

MAJOR

DEGREE

NUMBER

REQUIREMENTS

FERRED OR WILL

YEARS IN

FULFILLED

BE CONFERRED

 

 

 

 

PROGRAM

(MM/YYYY)

(MM/YYYY)

 

 

 

 

 

INTERNSHIP OR RESIDENCY COMPLETED (MUST PROVIDE CERTIFICATE), CURRENTLY SERVING, OR SCHEDULED TO COMMENCE

HOSPITAL OR INSTITUTION

(Include City, State, and ZIP)

FROM

(MM/YYYY)

TO

(MM/YYYY)

SPECIFY TYPE AND SPECIALTY (if applicable)

(e.g. Rotating, Mixed, or Straight,

Categorical, Surgery, Family Practice)

PHS-50 (Rev. 8/10)

PAGE 1 OF 6

PSC Graphics (301) 443-1090 EF

10.UNIFORMED SERVICE - List below in chronological order all service you have had in the ARMY, NAVY, AIR FORCE, MARINE CORPS, COAST GUARD, COMMISSIONED CORPS OF THE NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, and COMMISSIONED CORPS OF THE U.S. PUBLIC HEALTH SERVICE (PHS). NOTE : If U.S. Public Health Service, include PHS Serial Number. Include any present Uniformed Services affiliations: PHS, Reserve Unit, ROTC commitment, etc. Except for PHS affiliation, you will soon be asked to initiate a request for inter-service transfer, conditional release, or to provide proof of discharge, as may be applicable to your situation. No immediate action is required. Total active service time includes full-time active duty plus short tours. Do not add in reserve time when not on active reserve duty.

BRANCH OF

REGULAR

SERVICE

OR RESERVE

Example: Army, Navy, etc. COMPONENT

HIGHEST RANK

HELD

DUTY

FROM: (MM/DD/YYYY) TO: (MM/DD/YYYY)

ACTIVE OR

INACTIVE DUTY

TOTAL ACTIVE

NON-PUBLIC HEALTH

SERVICE TIME (In years and months)

11. Were you ever rejected for duty in any branch of a Uniformed Service?

Yes

No

If "Yes," state when and where rejected and cause:

12.DEPENDENTS INFORMATION (Full name of spouse and full name(s) and date(s) of birth of child(ren) and/or other dependent(s)): (Continue in Item 35 if needed)

 

(Name)

(Relationship)

(Date of Birth: MM/DD/YYY)

 

 

SPOUSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate Answers by Placing an "X" in the Appropriate Column.

 

 

 

 

 

 

 

 

YES NO

13.Have you ever received a Federal Government scholarship?

If Yes, check

Indian Health Service

National Health Service Corps

Length of Service obligation:

 

Years

 

appropriately:

Other Describe:

 

 

Has obligation been fulfilled?

Yes

No

 

 

14.Have you EVER been fired from a job or quit a job after being told you would be fired? (If "Yes," explain in item 35.)

15.Have you EVER received a military discharge that was not honorable? (If "Yes," explain in item 35.)

16.Have you EVER been arrested and/or convicted for any offense, by any police officer, sheriff, marshal, or any other type of law enforcement officer? Please include any arrests that did not result in a conviction or may have been dropped or expunged. (If "Yes," explain in item 35.)

17.Have you EVER been charged with any felony offense? (If "Yes," explain in item 35.)

18.Have you EVER been charged with an offense (misdemeanor or felony) that involved violence including assault, battery, domestic violence, or threats against persons? (If "Yes," explain in item 35.)

19.Have you EVER been charged with a firearms or explosives offense? (If "Yes," explain in item 35.)

20.Have you EVER been charged with any offense(s) related to alcohol or drugs? (If "Yes," explain in item 35.)

21.Have you EVER illegally used a controlled substance (i.e., marijuana, cocaine, crack cocaine, narcotics, stimulants, hallucinogens, steroids, depressants, inhalants, or prescription drugs? (If "Yes," explain in item 35.)

22.Are you delinquent on the repayment of any Federal debt(s)? (If "Yes," explain in item 35.) (Examples of Federal debt include delinquent taxes, audit disallowances, guaranteed or direct student loans, FHA loans, and other miscellaneous administrative debts. The definition of delinquency for the purposes of direct and guaranteed loans are any loan more than 31 days past due on a scheduled payment. Deferred loans are not considered delinquent.)

23.Are you a conscientious objector to military service? (If "No," go to Item 25.)

24.If you are a conscientious objector, are you willing to serve in a noncombatant position? (NOTE: By Executive Order, the PHS Commissioned Corps may be militarized during times of national emergency and does have officers serving in support roles at all times. If in this Item (24) you state an objection, you will be precluded from appointment in the Commissioned Corps of the U.S. Public Health Service.)

25.REFERENCES: List the names of four individuals who have knowledge of your "knowledge, skills, and abilities," including your most recent employer/supervisor, with whom you have had professional affiliation or training at some time during the past 7 years. Include, where applicable, Dean of College; Dean of Graduate or Professional school; Director of Intern Training Program; Director of Graduate, Post-Graduate, Residency, or Specialty training; chairperson of departments in which graduate or professional work was taken; or employment supervisors. Forward to these individuals form PHS-1813, "Reference Request for Applicants to the USPHS Commissioned Corps."

 

FULL NAME

PROFESSIONAL RELATIONSHIP TO

 

 

BUSINESS ADDRESS

 

APPLICANT

 

 

(Organization and Street, City, State, ZIP, Telephone)

 

 

 

 

 

 

 

 

 

 

 

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail address:

 

 

 

 

 

 

 

 

 

 

FAX No.:

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail address:

 

 

 

 

 

 

 

 

 

 

FAX No.:

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail address:

 

 

 

 

 

 

 

 

 

 

FAX No.:

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail address:

 

 

 

 

 

 

 

 

 

 

FAX No.:

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

PHS-50 (Rev. 8/10)

PAGE 2 OF 6

26.LIST STATES GRANTING FULL/UNRESTRICTED PROFESSIONAL LICENSES/CERTIFICATES/REGISTRATIONS (Include license or registry number and expiration date and provide a copy of the license/certificate/registration.) NOTE: Nurses must provide a photocopy of NCLEX certificate or other proof that this was the licensure examination taken.

LICENSE TYPE/NUMBER

STATE

STATUS (e.g., Active, Expired, Suspended, etc.)

EXPIRATION DATE (If applicable)

27.DRUG ENFORCEMENT ADMINISTRATION (DEA) CONTROLLED SUBSTANCE REGISTRATION INFORMATION (If you were never registered, so state.)

A.List all jurisdictions (past and present) where you are or were registered under Title 21, U.S. Controlled Substances Act, and provide your DEA controlled substance registration number for each jurisdiction.

(Explain all "Yes" answers in Item 35.)

YES NO

B.Has your registration under this Act ever been denied, suspended, revoked, refused renewal, or voluntarily surrendered?

C.Have you ever been charged with, or are currently facing charges of, a violation of the Controlled Substance Act?

28.STATUS IN PROFESSIONAL U.S. BOARDS (Indicate date and type of board, and whether Board Eligible, Board Certified, or Board Examination has been taken. Submit copy of ECFMG Certificate and Board Certification, if any. )

29. PROFESSIONAL PRACTICE QUESTIONS - If your answer to any of the following is "Yes," provide full details in item 35 but do not YES NO disclose specific medical information. (Questions must be answered even if not in a field where licensure is required.)

A.Have you EVER been denied membership or renewal thereof, or been subject to disciplinary proceedings by any medical or professional organization?

B.Have you EVER lost or had your professional practice license in any jurisdiction denied, restricted, limited, suspended, revoked, cancelled or placed on probation?

C.Have liability claims been filed against you, or against a hospital, corporation, or government based on a case under your care?

D.Have judgments or settlements been made against you, or against a hospital, corporation, or government based on a case directly under your care?

E.Have you EVER had, or are you about to have, your professional liability insurance declined, canceled, issued on special terms, or refused renewal?

F.Has your license EVER been subjected to probation either voluntarily or involuntarily?

G.Have any disciplinary actions or investigations been initiated against you by any State licensure board?

H.Have you EVER been cautioned, reprimanded, disciplined, censured and/or fined, by any local, State or Federal agency, licensing board, hospital medical board/staff, any institution, or any other professional organization/national professional society or regulatory agency?

I.Have you EVER voluntarily or involuntarily withdrawn your application for clinical privileges or terminated request for clinical privileges before a hospital or health facility's governing board made a decision?

J.Have any or all of your privileges at any health care facility EVER been, or are about to be limited, suspended, revoked, refused renewal, or voluntarily surrendered?

K.Have you EVER been reprimanded, censured, excluded, suspended and/or disqualified from participating in or voluntarily withdrawn to avoid an investigation by Medicare, Medicaid, TRICARE, and/or any other governmental health related programs?

L.Has any information pertaining to you, including malpractice judgments and or disciplinary action EVER been reported to the National Practitioner Data Bank or any other practitioner data bank?

M.Has your Federal DEA number and/or state controlled substance license EVER been suspended revoked, restricted, limited, or relinquished either voluntarily or involuntarily?

N.Have you EVER withdrawn from, or been suspended, dismissed, or expelled from a professional school or postgraduate training program or has any third party ever attempted to have you withdrawn, suspended, dismissed or expelled from a professional school or postgraduate training program?

O.Have you EVER been placed on probation or taken a leave of absence from a medical, dental, or other graduate school or postgraduate training program?

P.Do you have, or has it been suggested to you that you have, a history including the present, of any physical, mental, or emotional impairment that either you or an objective third party might think would limit your ability to meet the duties associated with clinical staff membership and which could require an accommodation for you to exercise your clinical privileges and clinical staff duties completely and safely? (if yes, please describe the accommodation needed.)

Q.Are you currently engaged in illegal use of any legal or illegal substances?

R.Are you currently participating in a supervised rehabilitation program and/or professional assistance program, which monitors you for alcohol and/or substance abuse?

30.Provide the names and addresses (past and present) of all of your professional liability insurers and your policy numbers.

PHS-50 (Rev. 8/10)

PAGE 3 OF 6

31. EMPLOYMENT HISTORY

Begin with current or most recent work or volunteer experience and work backward in time. Account for any periods of unemployment on the last line of the experience blocks in order of occurrence. Do not list any employment prior to commencing undergraduate school. For your PROFESSIONAL EXPERIENCE AND WORK RECORD, include professional training positions not reflected in Item 9. Include assistantships, apprenticeships, and fellowships. Describe your duties, including: (a) professional skills involved; (b) degree of responsibility; (c) complexity of duties; (d) extent of supervision received and exercised; (e) extent of public contact; and (f) extent of influence on policy. Provide all work experience - use photocopies of this page 4 to continue. Important: No part of this application may be completed by writing “See CV.” All parts of the application must be completed. Missing information will adversely affect your rank, pay, and future promotions.

DATES EMPLOYED (MM/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER / VERIFIER NAME / MILITARY DUTY

YOUR POSITION TITLE / MILITARY RANK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER ’S / VERIFIER’S STREET ADDRESS

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS OF JOB LOCATION

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S NAME & STREET ADDRESS (If different than

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

Job Location)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AVERAGE NUMBER OF HOURS PER WEEK (Indicate full or

KIND OF BUSINESS OR ORGANIZATION (e.g., education, health, social services, etc.)

part-time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REASON FOR LEAVING OR WISHING TO LEAVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION OF WORK (Describe your specific duties, responsibilities, and accomplishments in this job.)

DATES EMPLOYED (MM/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER / VERIFIER NAME / MILITARY DUTY

YOUR POSITION TITLE / MILITARY RANK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER ’S / VERIFIER’S STREET ADDRESS

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS OF JOB LOCATION

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S NAME & STREET ADDRESS (If different than

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

Job Location)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AVERAGE NUMBER OF HOURS PER WEEK ( Indicate full or

KIND OF BUSINESS OR ORGANIZATION (e.g., education, health, social services, etc.)

part-time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REASON FOR LEAVING OR WISHING TO LEAVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION OF WORK (Describe your specific duties, responsibilities, and accomplishments in this job.)

PHS-50 (Rev. 8/10)

PAGE 4 OF 6

31. EMPLOYMENT HISTORY (Continued)

DATES EMPLOYED (MM/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER / VERIFIER NAME / MILITARY DUTY

YOUR POSITION TITLE / MILITARY RANK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER ’S / VERIFIER’S STREET ADDRESS

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS OF JOB LOCATION

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S NAME & STREET ADDRESS (If different than

CITY (Country)

STATE

 

ZIP (+4)

 

 

 

 

 

 

TELEPHONE NUMBER

Job Location)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AVERAGE NUMBER OF HOURS PER WEEK ( Indicate full or

KIND OF BUSINESS OR ORGANIZATION (e.g., education, health, social services, etc.)

part-time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REASON FOR LEAVING OR WISHING TO LEAVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION OF WORK (Describe your specific duties, responsibilities, and accomplishments in this job.)

32. ADDITIONAL SKILLS AND QUALIFICATIONS

FOREIGN LANGUAGE: Do you have adequate competency to use any language(s) in performance of duty?

YES

NO If "Yes," specify language

and proficiency level. 1 = Elementary Proficiency, 2 = General Professional Proficiency, 3 = Functionally Native Proficiency

 

 

 

 

 

 

 

 

Language

Proficiency

Language

 

 

Proficiency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HONORS AND AWARDS (Acquired by academic or non-academic experience.)

NONDEGREE RELATED TRAINING (e.g., computer skills, public speaking, leadership recognition, American Council of Learned Societies (ACLS) fellowship program, Basic Life Support (BLS), Cardiopulmonary Resuscitation (CPR), Emergency Medical Services, etc.)

LIST CURRENT OR FORMER MEMBERSHIP IN PROFESSIONAL ASSOCIATIONS (Also indicate office(s) held and committee membership(s).)

PHS-50 (Rev. 8/10)

PAGE 5 OF 6

33.TYPES OF ASSIGNMENTS IN WHICH YOU ARE INTERESTED

Officers are required to serve in any area or climate or wherever the needs of the Commissioned Corps of the U.S. Public Health Service may require.

Do you have a preference for assignment to a particular program? Bureau of Prisons, etc.)

YES

NO If "Yes," which program? (e.g., Indian Health Service, Federal

GEOGRAPHIC AREAS IN WHICH YOU PREFER TO SERVE (i.e., Department of Health and Human Services Regional Areas are as follows: Region I: CT,

MA,NH,RI,VT,ME; Region II: NY,NJ,PR,VI; Region III: DE,MD,PA,VA,WV,DC; Region IV: AL,FL,GA,KY,MS,NC,SC,TN; Region V: IL,IN,MI,MN,OH,WI; Region

VI: AR,LA,NM,OK,TX; Region VII: IA,KS,MO,NE; Region VIII: CO,MT,ND,SD,WY,UT; Region IX: AZ,CA,HI,NV,GU,AP,AS; Region X: AK,ID,OR,WA.)

34. Do you have any personal objection to complying with Commissioned Corps of the U.S. Public Health Service uniform and grooming standards?

YES

NO

35.SPACE FOR DETAILED ANSWERS

(Indicate item numbers to which the answers apply. If more space is required, attach an 8 ½ x 11 inch sheet of paper. Write your name, present mailing address, and social security number on each sheet. NOTE: Specific personal medical information should not be disclosed.)

ATTENTION - THIS STATEMENT MUST BE SIGNED BY ALL APPLICANTS

Read the following paragraphs carefully before signing this Statement.

A false answer to any question in this Statement may be grounds for not appointing you, or for dismissing you after appointment, and may be punishable by fine or imprisonment (U.S. Code, Title, 18, Section 1001). All the information you give will be considered in reviewing your application.

AUTHORITY FOR RELEASE OF INFORMATION

I have completed this Statement with the knowledge and understanding that any or all items contained herein may be subject to investigation prescribed by law or Presidential directive and I consent to the release of information concerning my capacity and fitness by employers, educational institutions, law enforcement agencies, and other individuals and agencies, to duly accredited investigators, Personnel Staffing Specialists, and other authorized employees of the Federal Government for that purpose. I hereby release from liability all representatives of the Federal Government for their acts performed in good faith and without malice in connection with evaluating my credentials and qualifications, and I hereby release from any liability any and all individuals and organizations who provide information to these representatives in good faith and without malice concerning my professional competence, ethics, character, and other qualifications for appointment in the Commissioned Corps of the United States Public Health Service.

CERTIFICATION

I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I am willing to serve in any area or climate or wherever the needs of the Commissioned Corps of the U.S. Public Health Service may require.

PRINT OR TYPE NAME AND SIGN IN INK

DATE

PHS-50 (Rev. 8/10)

PAGE 6 OF 6

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