Fillable Phs-6300-1 FORM PHS 6300-1

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Phs-6300-1 FORM PHS 6300-1

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
MEDICAL SPECIAL PAY (MSP) CONTRACT REQUEST
(Privacy Act Notice on Reverse)
DCP USE ONLY
DATE REC.
CT. DATE
EXP. DATE
IDENTIFICATION
NAME (Last, First, Middle Initial)
GRADE/RANK
PHS SERIAL NUMBER
ORGANIZATION
DUTY PHONE NUMBER SSAN
SPECIAL PAY(S) REQUESTED (Check appropriate box(es))
Retention Special Pay (RSP) (1, 2,
3, or 4 year contracts)
Multiyear Retention Bonus (MRB)
(2, 3, or 4 year contracts, concurrent with RSP)
Incentive Special Pay (ISP)
(1 year--If MRB contract, rate of concur-
rent ISP fixed for duration of MRB)
CONDITIONS OF CONTRACT
In consideration of payment of the above requested special pay for which I qualify under 42 U.S.C. 210(a)(2), 37 U.S.C. 302(a)(4), 302(b), and 301d,
and implementing policies prescribed in INSTRUCTIONs 3, 9, and/or 10, Subchapter CC22.2, of the Commissioned Corps Personnel Manual (CCPM), I
hereby agree to the following:
A. To remain on active duty in the Public Health Service (PHS) Commissioned Corps for 12, 24, 36, or 48 consecutive months from the
effective date of this contract.
(Check Only One)
12 Months
24 Months 36 Months 48 Months
(a) Date I attain eligibility for MSP provided the completed contract is received in CB, DCP, within 60 days after I am initially eligible, and the
contract bears my signature, notarized within 30 days after I am initially eligible for MSP; or
(b) Date the completed contract is notarized if received in CB, DCP, within 60 days of the date of eligibility but has not been notarized within
30 days of the date of initial eligibility; or
(c) Later date, if eligible, specified by me, which is
(Month)
(Day)
(Year)
.
(1) Effective date for initial contracts shall be the:
(a) Date following the date the preceding contract expires, provided the completed contract is received in CB, DCP, within 60 days after the
date of expiration of the previous contract, and the contract bears my signature, notarized on or before the date following the date the
preceding contract expired; or
(b) Date the completed contract is notarized if received in CB, DCP, within 60 days after the date of expiration of the previous contract, but
has not been notarized on or before the date the previous contract expired.
(2) Effective date for subsequent contracts shall be the:
B. That the EFFECTIVE date shall be the DATE THE NOTARIZED CONTRACT IS RECEIVED in the Compensation Branch (CB), Division of
Commissioned Personnel (DCP), except for conditions listed below:
(1) I shall be required to refund a pro rata portion of any payment received pursuant to this contract. (For 1-year RSP and/or ISP and 2-year MRB
contracts, that portion that represents 1/360 of the annual payment for each day of the year not served. In the case of 3-year and 4-year MRB
contracts, the amount prorated will be the minimum bonus (2-year bonus amount)). The additional bonus amount for 3-year and 4-year
contracts will not be prorated and must be repaid in its entirety;
(2) I shall be divested of entitlements for travel and transportation allowances for myself and my dependents, shipment of household goods, use
of, transfer of, or payment for unused annual leave to my credit upon separation from the PHS Commissioned Corps;
(3) Any amount which I am obligated to refund because this contract is terminated shall be a debt due to the United States which I hereby agree
to pay in full as directed by the appropriate collections officials. In accordance with Treasury Fiscal Requirements Manual (1 TFRM 6-8000,
Cash Management), late charges may be assessed for payments made after the due date on amounts owed to the United States
Government; and
(4) I shall have my commission terminated.
C. If this contract is terminated prior to its expiration date for reasons other than as identified in F. below:
D. That a period of Absence Without Leave (AWOL) shall not be credited to fulfillment of the active-duty obligation incurred pursuant to this contract
and that the period of such active-duty obligation shall be extended by the number of days of AWOL.
E. That the policies (INSTRUCTIONs 3, 9, and/or 10, Subchapter CC22.2, of the CCPM) which implement the MSP provisions of 42 U.S.C. 210(a)
(2) and 37 U.S.C. 302(a)(4), 302(b), and 301d are incorporated into and made part of this contract.
F. That if I enter a long-term training program as defined in INSTRUCTION 1, Subchapter CC25.2, of the CCPM or medical internship or residency
training program (i.e., training which is creditable toward board certification) this contract shall be terminated and I shall repay an amount as
specified in C.(1) above.
G. That I am NOT ELIGIBLE for voluntary retirement for the duration of this contract.
CERTIFICATION
I certify that I understand and agree to the terms of this contract as stated above.
SIGNATURE
DATE
NOTARIZATION
Subscribed and sworn before me this day of
(MONTH)
, A.D.,
(YEAR)
.
at City State Zip Code
.
SIGNATURE
DATE COMMISSION EXPIRES
PHS-6300-1 (Rev. 04/98) (FRONT)
1st Copy DCP 2nd Copy OPERATING DIVISION/ PROGRAM 3rd Copy OFFICER
PSC Publishing Services (30) 443-6740
EF
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SUPERVISOR CERTIFICATION
(Check below as appropriate)
This is to certify that the officer meets the following conditions:
Will not be participating in long-term training or medical internship or first year of residency training as defined in INSTRUCTION 1, CC25.2 of the
CCPM;
Is performing at a satisfactory level; and
Has received a competent or above performance rating on the current Commissioned Officers’ Effectiveness Report as required by
INSTRUCTION 1, CC25.1of the CCPM.
IS RECOMMENDED FOR:
Retention Special Pay contract requested. Multiyear Retention Bonus contract requested.
Incentive Special Pay contract requested.
IS NOT RECOMMENDED for Medical Special Pay contract(s). A written explanation must accompany this contract.
SIGNATURE
TITLE DATE
OPERATING DIVISION/PROGRAM CERTIFICATION
I certify that this officer is eligible to receive this bonus and I recommend payment.
SIGNATURE
TITLE DATE
Privacy Act Notice for
PHS Commissioned Corps Medical Special Pay (MSP)
Contract Form PHS-6300-1
General: This information is provided pursuant to the Privacy Act of 1974 (Public Law 93-579) for PHS
commissioned medical officers applying for MSP.
Records System: 09-37-0002, "PHS Commissioned Corps General Personnel Records," HHS/OASH/OSG;
09-37-0003, "PHS Commissioned Corps Medical Records," HHS/OASH/OSG; 09-37-0005, "PHS Commissioned
Corps Board Proceedings," HHS/OASH/OSG; 09-37-0006, "PHS Commissioned Corps Grievance, Investigatory,
and Disciplinary Files," HHS/OASH/OSG; 09-37-0008, "PHS Commissioned Corps Unofficial Personnel Files and
Other Station Files," HHS/OASH/OSG; and 09-90-0017, "Pay, Leave and Attendance Records," HHS/OS/ASPER.
Authority for Collection of Information: 37 U.S.C. 302(a)(4), 302(b), and 301d (Pay and Allowances of the
Uniformed Services); 42 U.S.C. 202 et seq. (PHS Act Sec 201 et seq.); and Executive Order 9397 (Numbering
System for Federal Accounts Relating to Individual Persons).
Purposes and Uses: The principal purpose for collecting this information is to determine your eligibility for MSP. If
you are selected for award of MSP, the information collected will be used for issuance of personnel orders to
authorize payment. These records, or information therefrom, may also be provided to other Federal agencies to
which Corps medical officers are assigned. The information also may be used for study purposes and/or collection
of statistical data for reports to other Federal agencies and the Congress. It may also be used for other lawful
purposes including collection of a debt owed the Federal Government, law enforcement, and litigation.
Information Regarding Disclosures of Your Social Security Number (SSAN): Disclosure of the SSAN is
mandatory under provisions of the Social Security Act, since Corps officers are under Social Security "covered
employment" and taxes must be withheld from their salaries. The SSAN is also used as an identifier throughout an
officer’s career. It is used primarily to identify an officer’s personnel, leave, and pay records and to relate one to
the other. The SSAN is also used in connection with lawful requests for information from former employers,
educational institutions, and financial or other organizations. The information gathered through the use of the
number will be used only as necessary in personnel administration processes carried out in accordance with
established regulations and published notices of systems of records. The use of the SSAN is made necessary
because of the large number of present and former active, inactive, and retired officers and applicants who have
identical names and birth dates, and whose identities can only be distinguished by the SSAN.
Effect of Nondisclosure: You are required to provide the information requested on this contract to receive MSP.
Failure to supply complete and accurate information may result in delays and/or errors in determining eligibility
and, therefore, result in late payment or nonpayment, or be cause for refund of pay if you receive an award based
on erroneous information. All statements are subject to verification.
PHS-6300-1 (Rev. 04/98) (BACK)
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NOTICE: Signature block for "Supervisor Certification" and "Agency/Operating Division/Program Certification"
appear on the 1st copy of this form.
Privacy Act Notice for
PHS Commissioned Corps Medical Special Pay (MSP)
Contract Form PHS-6300-1
General: This information is provided pursuant to the Privacy Act of 1974 (Public Law 93-579) for PHS
commissioned medical officers applying for MSP.
Records System: 09-37-0002, "PHS Commissioned Corps General Personnel Records," HHS/OASH/OSG;
09-37-0003, "PHS Commissioned Corps Medical Records," HHS/OASH/OSG; 09-37-0005, "PHS Commissioned
Corps Board Proceedings," HHS/OASH/OSG; 09-37-0006, "PHS Commissioned Corps Grievance, Investigatory,
and Disciplinary Files," HHS/OASH/OSG; 09-37-0008, "PHS Commissioned Corps Unofficial Personnel Files and
Other Station Files," HHS/OASH/OSG; and 09-90-0017, "Pay, Leave and Attendance Records," HHS/OS/ASPER.
Authority for Collection of Information: 37 U.S.C. 302(a)(4), 302(b), and 301d (Pay and Allowances of the
Uniformed Services); 42 U.S.C. 202 et seq. (PHS Act Sec 201 et seq.); and Executive Order 9397 (Numbering
System for Federal Accounts Relating to Individual Persons).
Purposes and Uses: The principal purpose for collecting this information is to determine your eligibility for MSP. If
you are selected for award of MSP, the information collected will be used for issuance of personnel orders to
authorize payment. These records, or information therefrom, may also be provided to other Federal agencies to
which Corps medical officers are assigned. The information also may be used for study purposes and/or collection
of statistical data for reports to other Federal agencies and the Congress. It may also be used for other lawful
purposes including collection of a debt owed the Federal Government, law enforcement, and litigation.
Information Regarding Disclosures of Your Social Security Number (SSAN): Disclosure of the SSAN is
mandatory under provisions of the Social Security Act, since Corps officers are under Social Security "covered
employment" and taxes must be withheld from their salaries. The SSAN is also used as an identifier throughout an
officer’s career. It is used primarily to identify an officer’s personnel, leave, and pay records and to relate one to the
other. The SSAN is also used in connection with lawful requests for information from former employers, educational
institutions, and financial or other organizations. The information gathered through the use of the number will be
used only as necessary in personnel administration processes carried out in accordance with established
regulations and published notices of systems of records. The use of the SSAN is made necessary because of the
large number of present and former active, inactive, and retired officers and applicants who have identical names
and birth dates, and whose identities can only be distinguished by the SSAN.
Effect of Nondisclosure: You are required to provide the information requested on this contract to receive MSP.
Failure to supply complete and accurate information may result in delays and/or errors in determining eligibility and,
therefore, result in late payment or nonpayment, or be cause for refund of pay if you receive an award based on
erroneous information. All statements are subject to verification.
PHS-6300-1 (Rev. 04/98) (BACK)
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Completed 27 February 2020

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