The Federal Bureau of Investigation’s Control Over Weapons and Laptop Computers Follow-Up Audit
Audit Report 07-18
Office of the Inspector General
FD-193 (Rev. 12-5-02)
Report of Exit and Separation
|Name of Employee:||EOD Date:||Title:|
(hour and last day physically at work):
(include workweek if other than Monday-Friday):
|Interview Conducted by (signature):||Title:|
Read Before Interviewing
Purposes: Serves as a basis for (1) information supplied by Bureau upon request by State Unemployment Compensation Boards, (2) accurate analysis of turnover, (3) determining necessary or desirable organizational improvements, and (4) permitting a recorded recommendation regarding future reinstatement (5) and ensuring the return of government property.
When and Where Conducted: As promptly as possible after receipt of resignation in adequate privacy with adequate time.
Reasons Given for Separation: The reason that the employee documented on the SF-52, and the electronic entry of same into BPMS, should be placed in only one corresponding category of reason.
|01 Resignation||06 Military|
|02 Optional||08 Reduction-in-Force (RIF)|
|03 Mandatory||09 Other Federal Agency (Complete A listed below)|
|04 Disability||10 Removal|
|05 Discontinued Service||11 Other ___________________________________|
Comments: If employee is transferring to another federal government agency, state what agency transferring to, the address, and when employment will begin on the back of the form SF-52, Request for Personnel Action.
Employee was advised by interviewing official that employment information beyond name, past and present positions, titles, grades, salaries, duty stations, and reason for separation as shown on the Notification of Personnel Action may be disseminated if a prospective employer is a Federal Agency or a state or local agency within the criminal justice community, without the written consent of the employee. Yes No
Did employee resign prior to expiration of any agreement made not covered in #1, such as to remain a specific period following initial appointment or following special training? Yes No If yes, specify agreement(s) involved and explain.
If support employee, did employee resign within 182 days of entrance on duty owing advanced salary? Yes No
If answer to either question 1, 2, or 3 above is Yes and/or employee has advanced leave:
Will the employee be indebted to the U.S. government? Yes No
If yes: How does employee intend to discharge this debt?
Advise employee that interest can be charged on overdue payments at the current Treasury rate.
Advise employee any money due will be held in abeyance until determination is made as to any indebtedness.
Employee has been advised concerning Post-Employment Restrictions in the Ethics Reform Act of 1989, as detailed in Part I, Section 1-1 (11) of the Manual of Administrative Operations and Procedures. Yes No (If No, explain why.)
Employee has been afforded a debriefing by his/her respective Security Officer.
Yes No (If No, explain why.)
All documents made or received while in the FBI's service will be collected on date employee ceases active duty (exceptions: Commendations, censure or promotion letters or copies of expense vouchers, etc.) Yes No
If employee is resigning for maternity purposes, appropriate block must be marked:
Even though the employee may be incapacitated for duty following the cease-active-duty date, she is not entitled to a lump sum payment for sick leave.
Doctor's certificate attached indicating (1) employee is incapacitated for duty after indicated cease-active-duty date, and (2) expected date of confinement.
Doctor's certificate attached indicating employee can safely continue working until date specified. (Applicable to those cases where the employee desires to work up to less than 6 weeks before expected date of delivery.)
Was employee advised that any inquires concerning his/her FBI employment should be directed to FBI, JEH Building, 935 Pennsylvania Ave., N. W. Washington, D.C. 20535, as such information is not available elsewhere? Yes No
Was retiring employee (including approved disability retirements) advised that his/her credentials/identification card and SA badge will be mounted on a retirement plaque and forwarded to him/her? Yes No Property to be mounted on the plaque should be forwarded to FBIHQ, Retirement Office, Room 1829.
For Special Agents Only: Employee was presented with Form FD-755 regarding release of personal information. Yes No (If no, explain why.)
For Resigning Employees Only: Does employee understand that favorable consideration may not be given for reinstatement unless reason(s) for resigning were compelling and beyond employee =s control? Yes No
For Resigning Employees Only: Employee was presented with the Standard Form 8, Notice to Federal Employee About Unemployment Insurance at this time. Yes No (If no, explain why.)
(1) Reports from the Property Management Application have been reviewed and all property listed for the employee will be collected on the last day of employment, Yes No (If No, explain why.) (2) Reports from the Bureau Personnel Management System/Issued Personal Property Subsystem will be reviewed and all property will be returned on the last day of employment, Yes No. (If no, explain why.) (3) All other automated and manual records will be reviewed for property charged to the employee and all property will be returned, Yes No. (If no, explain why.) (4) Documentation has been verified that all firearms issued to the employee will be retrieved and returned to the Training Division, Weapons Management Facility upon separation.
Recommendation re reinstatement: Yes No. (If no, explain why.)
Please have employee read and sign items 1, 2, 3, and 4, if applicable; however, if resignation tendered during personnel action inquiry, advise employee of the Bureau's procedures for employee discipline and have employee sign items 1, 2, 3, 4, and 5.
I understand that this is a voluntary resignation and, as such, may under applicable law, disqualify me totally or in part from receiving unemployment compensation.
I hereby waive my rights under the Privacy Act of 1974, 5 United States Code 552a, and authorize the FBI to release to any state unemployment compensation commission, or other such governmental agency, information from my personnel records concerning my separation from duty for the limited purpose of providing information to that agency so that it might assess my qualification for unemployment compensation.
For resignations only: I understand that I have two options regarding my health benefits coverage. (Employees who are retiring from FBI service will be advised by the Retirement Office of their options into retirement.) The first option is that after my 31 days of free coverage have ended, I may convert my health coverage to an individual plan with no waiting period for benefits. The other option is that I may continue my health benefits coverage by paying the employee share and the government share of the premium, plus an additional two percent administrative fee. Further information regarding continuation of health benefits may be obtained by calling the Employee Benefits Unit (EBU), FBIHQ, (202) 324-3771. This request must be received by EBU within 60 days after separation from the Bureau.
I understand that Federal Law prohibits former government employees from retaining government property, including classified and/or sensitive information, firearms and other property issued to me while I was an employee of the FBI. I understand that I may be prosecuted for possession of classified information, (as defined in MIOG, Part II, Section 35-12 (13) and (63). I further understand that pursuant to 41 CFR 128-51, I may be subject to financial recovery action for lost or stolen government property which was assigned to me. I affirm that I have returned all classified and/or sensitive information and government property that was in my custody as an FBI employee.
I understand that I am the subject of a personnel action inquiry. Depending on the outcome of this inquiry, my position with the FBI could be terminated. I have been advised of and understand the Bureau's procedures for employee discipline and that these procedures in certain cases allow me the opportunity to respond to any allegations and/or changes. Also, I understand that these procedures allow me in certain cases to demonstrate any facts tending to mitigate my actions. I fully understand that it is not at all certain, at this time, that I will be dismissed. Nevertheless, I am hereby voluntarily resigning, and, therefore, freely giving up the opportunities provided by the FBI's disciplinary procedures.
This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals supplying information for completion of the Report of Exit and Separation Form.
Title 28, Code of Federal Regulations, Section 0.137, authorizes the Director of the FBI to exercise power and authority vested in the Attorney General by law to take final action in matters pertaining to the employment, direction and general administration of personnel in the FBI.
PURPOSES AND USES
Information concerning your reason for leaving the FBI will be placed on your final Notification of Personnel Action and will be furnished to prospective employers upon their request. This information may also be used to determine your suitability for reinstatement in the FBI should you apply for reemployment.
EFFECTS OF NONDISCLOSURE
Disclosure of the information requested is voluntary; however, failure to supply the information may result in no reason being given for your separation from the FBI on your Notification of Personnel Action and/or your not being considered favorably for reinstatement.
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