Free VA Form VA0120 - VA Police Officer Pre-Employment Screening Checklist - Federal

OMB Approved No. 2900-0524 Respondent Burden: 10 Minutes

VA POLICE OFFICER PRE-EMPLOYMENT SCREENING CHECKLIST
PRIVACY ACT STATEMENT: The information provided on VA Form 0120 will be confidential and protected by the Privacy Act of 1994 (5 U.S.C. 522a) and the VA's Confidentiality statue (38 U.S.C. 5701) as implemented by 38 CFR 1.576(b). Assurances of confidentiality are provided in the system of records identified as "Personnel Investigation Records, OPM/Central 9." RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number. The information requested is approved under OMB Control Number 2900-0524, and is necessary to accomplish the pre-employment screening to determine the qualification and suitability of the applicant to be hired as a VA police officer. This information is solicited under authority of Title 38, United States Code. Responding to this collection of information is voluntary and failure to furnish this information will have no other adverse effect. Public reporting burden for this collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this burden to VA Clearance Officer (005E3), 810 Vermont Ave., Washington, DC 20420. SEND COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUEST FOR BENEFITS TO THIS ADDRESS. FBI ORI.
A. LAST NAME, FIRST NAME, MIDDLE INITIAL FACILITY LOCATION

PART I - APPLICANT

B. SOCIAL SECURITY NO.

C. DATE OF BIRTH

D. SEX

PART II - ARREST RECORD CHECKS AND CERTIFICATION - BY CHIEF OF POLICE (Purpose Code: Criminal Justice Employment)
NO RECORD A. CHECK CRIMINAL RECORD REPOSITORY STATES CHECKED B. CHECK OF F.B.I. NATIONAL CRIME INFORMATION CENTER NO RECORD RECORD (Attach explanation of charges and disposition)

RECORD (Attach explanation of charges and disposition)

CERTIFICATION: I have reviewed the application and the above candidate has the type of experience that provided the knowledge, skills, and abilities to successfully perform the duties of a VA police officer.
SIGNATURE OF CHIEF OF POLICE DATE

Submit by Email to your local HR Mana
PART III - TELEPHONE CHECKS (Human Resources Management) INSTRUCTIONS: Determine quality of work history for all employment within the past 5 years. Verify all employment used for qualifiction regardless of age. A
1. NAME OF EMPLOYER 2. NAME AND TITLE OF CONTACT 3. DID APPLICANT'S DUTIES INCLUDE PROTECTION OF PERSONS & PROP. 4. INCLUSIVE DATES OF EMPLOYMENT 5. NUMBER OF HOURS PER WEEK 6. WAS APPLICANT'S QUALITY OF WORK SATISFACTORY? 7. WAS APPLICANT'S HONESTY AND CHARACTER SATISFACTORY? 8. APPLICANT'S REASON FOR LEAVING 9. WOULD YOU REHIRE APPLICANT? SIGNATURE AND TITLE OF INQUIRER DATE

B

C

PART IV - BASIS FOR QUALIFICATION AND CERTIFICATION (Human Resources Management)
ACCEPTABLE JOB EXPERIENCE MEETING GS-083 MINIMUM QUALIFICATION REQUIREMENTS. ACCEPTABLE SUBSTITUTE EDUCATION EVIDENCED BY TRANSCRIPT COPY. ______ YEARS ACTIVE MILITARY SERVICE IN THE QUALIFYING SPECIALTY OF:

ARMY: MARINE CORPS: AIR FORCE:

95B 5803 08111-114 3P1-4

95C 5805 81110 3P011

31A 5811 81170 3P031

31B 5812 81172 3P051 5813 81130 3P071 5814 81150 3P091 5821 81112 75011 81132 75031 81152 75051 81199 75071 75091

(No code) 9545 0000MA NAVY: COAST GUARD: Military service in the above checked specialty verified by review of DD Form 214, Certificate of Release of Discharge from Active Duty or other official document. (If other specify: ________________________________________________.) CERTIFICATION: Human Resources Management Service certifies that the applicant is suitable and meets current qualification standards for the GS-083 Police Officer series. Telephone interviews have been satisfactorily completed and documented in Part III of this form. SIGNATURE AND TITLE OF VERIFIER VA FORM MAY 2009 DATE

Submit by Email

0120

1 - VA POLICE INVESTIGATIVE RECORDS FILE (OPM/Cntral 9)

OMB Approved No. 2900-0524 Respondent Burden: 10 Minutes

VA POLICE OFFICER PRE-EMPLOYMENT SCREENING CHECKLIST
PRIVACY ACT STATEMENT: The information provided on VA Form 0120 will be confidential and protected by the Privacy Act of 1994 (5 U.S.C. 522a) and the VA's Confidentiality statue (38 U.S.C. 5701) as implemented by 38 CFR 1.576(b). Assurances of confidentiality are provided in the system of records identified as "Personnel Investigation Records, OPM/Central 9." RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number. The information requested is approved under OMB Control Number 2900-0524, and is necessary to accomplish the pre-employment screening to determine the qualification and suitability of the applicant to be hired as a VA police officer. This information is solicited under authority of Title 38, United States Code. Responding to this collection of information is voluntary and failure to furnish this information will have no other adverse effect. Public reporting burden for this collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this burden to VA Clearance Officer (005E3), 810 Vermont Ave., Washington, DC 20420. SEND COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUEST FOR BENEFITS TO THIS ADDRESS. FBI ORI.
A. LAST NAME, FIRST NAME, MIDDLE INITIAL FACILITY LOCATION

PART I - APPLICANT
B. SOCIAL SECURITY NO. C. DATE OF BIRTH D. SEX

PART II - ARREST RECORD CHECKS AND CERTIFICATION - BY CHIEF OF POLICE (Purpose Code: Criminal Justice Employment)
A. CHECK CRIMINAL RECORD REPOSITORY NO RECORD RECORD (Attach explanation of charges and disposition) STATES CHECKED B. CHECK OF F.B.I. NATIONAL CRIME INFORMATION CENTER NO RECORD RECORD (Attach explanation of charges and disposition)

CERTIFICATION: I have reviewed the application and the above candidate has the type of experience that provided the knowledge, skills, and abilities to successfully perform the duties of a VA police officer.
SIGNATURE OF CHIEF OF POLICE DATE

Submit by Email to your local HR Management

PART III - TELEPHONE CHECKS (Human Resources Management) INSTRUCTIONS: Determine quality of work history for all employment within the past 5 years. Verify all employment used for qualifiction regardless of age. A
1. NAME OF EMPLOYER 2. NAME AND TITLE OF CONTACT 3. DID APPLICANT'S DUTIES INCLUDE PROTECTION OF PERSONS & PROP. 4. INCLUSIVE DATES OF EMPLOYMENT 5. NUMBER OF HOURS PER WEEK 6. WAS APPLICANT'S QUALITY OF WORK SATISFACTORY? 7. WAS APPLICANT'S HONESTY AND CHARACTER SATISFACTORY? 8. APPLICANT'S REASON FOR LEAVING 9. WOULD YOU REHIRE APPLICANT? SIGNATURE AND TITLE OF INQUIRER DATE

B

C

PART IV - BASIS FOR QUALIFICATION AND CERTIFICATION (Human Resources Management)
ACCEPTABLE JOB EXPERIENCE MEETING GS-083 MINIMUM QUALIFICATION REQUIREMENTS. ACCEPTABLE SUBSTITUTE EDUCATION EVIDENCED BY TRANSCRIPT COPY. ______ YEARS ACTIVE MILITARY SERVICE IN THE QUALIFYING SPECIALTY OF:

ARMY: MARINE CORPS: AIR FORCE:

95B 5803 08111-114 3P1-4

95C 5805 81110 3P011

31A 5811 81170 3P031

31B 5812 81172 3P051 5813 81130 3P071 5814 81150 3P091 5821 81112 75011 81132 75031 81152 75051 81199 75071 75091

(No code) 9545 0000MA NAVY: COAST GUARD: Military service in the above checked specialty verified by review of DD Form 214, Certificate of Release of Discharge from Active Duty or other official document. (If other specify: ________________________________________________.) CERTIFICATION: Human Resources Management Service certifies that the applicant is suitable and meets current qualification standards for the GS-083 Police Officer series. Telephone interviews have been satisfactorily completed and documented in Part III of this form. SIGNATURE AND TITLE OF VERIFIER VA FORM MAY 2009 DATE

Submit by Email

0120

2 - Photocopy to VA Law Enforcement Training Center (Little Rock, AR)