PERSONAL QUALIFICATIONS STATEMENT
PATIENT SAFETY SPECIALIST/CLINICAL RISK MANAGER
1. Every
item on the Personal Qualifications Statement (PQS) must be addressed. Please sign and date in each required
location. Any additional information
required may be provided on a separate sheet of paper (indicate by number and
section the question(s) to be addressed).
2. The information you provide will be used to
determine whether you meet the minimum qualifications required by the
solicitation.
3. If you
submit false information the contract may be terminated for default. This action may initiate the suspension and
debarment process, which could result in the determination that you are no
longer eligible for future government contracts.
4. Health
certification. Individuals providing
services under government contracts are required to undergo a physical exam
within 60 days prior to beginning work.
The exam is not required prior to award but is required prior to the
performance of services under contract. By
signing this form, you have acknowledged this requirement.
5. Health Care Worker
Certificate Of Availability: I have agreed to provide services as a Patient
Safety Specialist/Clinical Risk Manager at Naval Hospital/Naval Medical
Center__________________________ [name of medical treatment facility] as an
employee or subcontractor [CIRCLE
ONE] for ______________________ [name of contractor firm]. I am available to begin providing these
services on ____________________ [date].
Signature
_______________ญญญญญญญญญญญญญ____________________
Date ___________________________________
6. Privacy act statement
Under 5 U.S.C. 552a and executive order 9397, the information provided on this page and the personal qualifications statement is requested for use in the consideration of a contract; disclosure of the information is voluntary; failure to provide information may result in the denial of the opportunity to enter into a contract. I understand the provisions of the Privacy Act of 1974 and Executive Order 9397 as related to me through the foregoing statement.
Date
___________________________________
Personal Qualifications Statement
PATIENT SAFETY SPECIALIST/CLINICAL RISK MANAGER
I. General Information
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Name |
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SSN |
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Address |
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Phone |
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II.
Professional Education (List qualifying professional education)
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Name of accredited school and
location |
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Completion Date of Training |
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III. Professional Licensure and Certification
(List each required license and certification):
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License and/or Certification |
Issuing Agency or State |
Date of License/Certification |
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IV. Microsoft
Application Proficiency
Do you possess proficiency with software
applications to include the following:
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Microsoft
Application |
Yes |
No |
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Word |
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Excel |
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Access |
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PowerPoint |
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Other |
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V. Professional Employment List your current
and preceding employers, starting from the most recent:
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Name and address
of employer |
Position held |
Dates |
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From |
To |
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VI. Current Navy contracts
Are
you are currently employed on a navy contract?
Yes _______ No _______ If
Yes, where is your current contract and what is the position?
_________________________________________________________ When does the contract expire? ____________________
VII. Employment eligibility
Do
you meet the requirements for U.S. Employment Eligibility? Yes ________ No _________
VIII. English fluency
Do
you read, write, speak, and understand the English language fluently? Yes ________ No _________
I hereby certify the information provided in this
PQS to be true and accurate. I further
acknowledge that I will submit any and all evidence of my qualifications, as
may be determined necessary by the requiring military medical treatment
facility.
Signature
_______________ญญญญญญญญญญญญญ____________________
Date ___________________________________