Official Federal Forms > US Office Of Personnel Management > OPM
Coverage Determination Application OPM 1676 - Official Federal Forms
| Coverage Determination Application Form. This is a national form and can be used in OPM US Office Of Personnel Management . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
United States Office of Personnel Management Coverage Determination Application CDA USER PROFILE Section I - Applicant Information New CDA UserID Existing CDA UserID CDA UserID (Furnish CDA UserID in CDA UserID box on left.) (Furnish CDA UserID in CDA UserID box on left.) Modify existing CDA UserID Specify effective date: Deactivate CDA UserID Specify deactivation date: (Furnish CDA UserID in CDA UserID box on left.) Specify what is being modified (Name, type of access, etc.) Federal Employee Permanent Temporary Exp. Date: Agency Name: Department: (If applicant is a contractor, a Federal employee supervisor must fill out form and have contractor sign and date in blocks 7 and 8.) Contractor Company: Contract Number: 1. Name (Last, First, Middle Initial) Expiration Date of Contract: Agency Name: Department: 2. Telephone Number (Include Area Code and Extension) 3. Last Four Digits of Social Security Number 4. Title/Position 5. Duty Location (City, State, Zip Code) 6. E-mail address Computer UserID and Password Disclosure Statement I understand that my UserID and password are for my use only. I agree to protect my password from disclosure by all reasonable means, and not willingly divulge it or allow its use by any other person(s). If I believe that another person has learned my password, I will notify my supervisor immediately. I understand that my use of Government equipment, including computer systems, must comply with the policies specified in the OPM "Policy on the Use of Government Office Equipment." If I am an employee of an agency other than OPM, I must also comply with my Agency's policy. I must also read, sign and date the Rules of Behavior on page 3. 7. Signature of applicant 8. Date of signature (mm/dd/yyyy) Section II - Federal Supervisor Information on page two (2) must be completed by your supervisor. OPM 1676 Revised May 2009 Page 1 of 3 Previous edition is not usable American LegalNet, Inc. www.FormsWorkFlow.com Section II - Applicant's Federal Supervisor Information (Applicant's Federal Supervisor must complete this section) 9. Grant the applicant the following CDA user access. Check one box. General Access - (Create employee record, update record, execute coverage determination, and view record) General Access with Manual Override - (General Access PLUS manual override authority, an authorization in the CDA that is generally granted to senior staff and supervisors. It is used when a retirement coverage determination made by the CDA differs from the retirement plan of record that was entered by the CDA user. Someone in your office should have this authority.) 10. Applicant's Federal Supervisor Name (Last, First, Middle Initial) (The approving official must be a Federal employee supervisor.) 11. Title/Position 12. Telephone Number (Include Area Code and Extension) 13. Duty Location (City, State, ZIP Code) 14. E-mail address 15. Must complete for All New CDA UserID Requests - Supervisor must provide status of Background Investigation of new user. Provide date in either the "Completed On" or "In Progress" area and your initials. Completed On Date: In Progress Date CDA UserID should be activated (if in progress): Supervisor's Initials: 16. Supervisor's signature Supervisor's Initials: 17. Date of signature (mm/dd/yyyy) All information and proper signatures must be completed or this User Profile Form will not be processed. If you have any questions, please contact OPM at: 1-800-239-2492 or CDAHelp@opm.gov. After you complete this form online, print form, and sign and date blocks 7 and 8. Your supervisor completes Section II, signs and date blocks 16 and 17. You must read the "Rules of Behavior, " (page 3), sign and date. Fax all 3 pages of this form to: (202) 606-1108. We cannot accept a completed form by email. Section III - OPM Security Officer Information (To be completed by OPM Security Officers Only) 18. Comments 19. Signature of OPM Designated Security Officer (DSO) 20. Date of signature (mm/dd/yyyy) OPM 1676 Revised May 2009 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Rules of Behavior (OPM Computer User Responsibilities) As a user of OPM's computer systems, you are expected to understand and comply with the responsibilities outlined below. You will be held accountable for your actions when using these systems. If you violate OPM policy regarding these responsibilities, you may be subject to administrative action ranging from counseling to removal from the Agency, as well as any criminal penalties or financial liability, depending on the severity of the misuse. As required by OPM policy, users of OPM's Coverage Determination Application (CDA) have responsibilities for protecting OPM's information resources from loss; theft; misuse; destruction; and unauthorized access, disclosure, modification or duplication. Privacy While Using Government Equipment - You do not have the right to privacy while using any Government equipment, including Internet or email services. Furthermore, your use of Government office equipment, for whatever purpose, is not secure, private or anonymous. While using Government office equipment, your use may be monitored or recorded. Protection of Software, Data and Hardware - You are not allowed to introduce any unauthorized software and data (including software and data protected by copyright, trademark, privacy laws, other proprietary data or material with other intellectual property rights beyond fair use), hardware or telecommunications devices or modify any configurations. In addition, you will protect all sensitive information residing in OPM computer systems, preventing unauthorized access, use, modification, disclosure or destruction of that information. This includes records about individuals requiring protection under the Privacy Act, sensitive financial information and information that cannot be released under the Freedom of Information Act. Disclosure of sensitive information, trade secrets and intellectual property to unauthorized individuals is also prohibited. Service Restoration - The availability of the computer systems is a matter of importance to you. You are responsible for assisting in any way that you can for restoring service in the event the computer systems becomes non-operational. System Privileges - You are given access to the computer systems based on a need to perform specific work. You are expected to work within the confines of the access allowed and are not to attempt to access systems or applica
|
|||||||
