Free 2097 - Federal

NAME OF EMPLOYEE (Type or Print)
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION

CERTIFICATION FOR SEPARATING EMPLOYEES

ORGANIZATION

This form is completed by officers and employees associated with carrying out FDA Programs as follows: FDA regular employees, PHS Commissioned Corps personnel, and Federal assignees under the Intergovernmental Personnel Act of 1970. Your attention is directed to certain statutory prohibitions for employees who leave the employment of the U.S. Government. These portions are summarized below. A. Post employment restrictions, 18 U.S.C. 207, stipulates that after having been employed by the United States: 1. 207 (a)(1). At any time after employment has ceased, a former Government employee shall not knowingly make any communication to or appearance before, with the intent to influence, any officer or employee of any department, agency, court of the United States or the District of Columbia, in connection with a particular matter involving a specific party or specific parties in which the United States is a party or has a direct or substantial interest, and in which while employed, the former Government employee participated personally and substantially. Within two years after employment has ceased, a former Government employee shall not knowingly make, with the intent to influence, communication to or appearance before any officer or employee of the United States Government on behalf of any other person in any matter in which the United States is a party to or has a direct and substantial interest, which matter was pending under the former employee's official responsibility during the last year of Government employment and which involved specific parties at the time it was pending. Any former employee of the Government who personally and substantially participated in ongoing trade or treaty negotiation on behalf of the United States within the one-year period preceding his or her termination from Government service, and had access to information concerning the trade or treaty negotiation which is exempt from disclosure under section 552 of Title 5, shall not on the basis of that information, knowingly represent, aid or advise any other person except the United States concerning such ongoing negotiations for a period of one year after his or her employment with the United States ended. Within one year after employment has ceased, Senate confirmed Presidential appointees employed at a rate of pay specified on the Executive Schedule (Ex) levels II through V, employees whose rate of basic pay is equal to or greater than the rate of basic pay for level V of the Executive Schedule and officers in the Commissioned Corps assigned to pay grades of 07 or above, are restricted from knowingly making, with the intent to influence, any communication or appearance before FDA on behalf of any other person, in connection with any matter on which the person seeks official action by FDA. For a period of one year after Government employment has ceased, any former employee who was employed at the pay levels described in 207(c) may not represent, aid or advise a foreign entity with the intent to influence a decision of any officer or employee of any Department or Agency of the United States, in carrying out his or her official duties.

2. 207 (a)(2).

3. 207 (b).

4. 207 (c).

5. 207 (f).

B.

21 U.S.C. 331 (j) prohibits: The using by any person to his/her own advantage, or revealing, other than to the Secretary or officers or employees of the Department, or to the courts when relevant in any judicial proceeding under this chapter, any information acquired under authority of section 344, 348, 350a, 355, 360, 360b, 360c, 360d, 360e, 360f, 360h, 360i, 360j, 374, 379, or 379e, of this title concerning any method or process which as a trade secret is entitled to protection.

C.

42 U.S.C. 423 (f), the Procurement Integrity Act, prohibits: An employee who was a procurement official with respect to a particular procurement from (1) participating on behalf of a competing contractor in any negotiations leading to the award, modification, or extension of a contract for such procurement, or (2) participating personally and substantially on behalf of the competing contractor in the performance of such contract, for a period of two years after the date of the employee's last personal and substantial participation in the procurement on behalf of the Government.

D.

Section 3(d) of the Federal Workforce Restructuring Act of 1994 provides that any former employee who accepted a buyout under the Act and then accepts employment--including employment under a personal services contract--with the Government within five years of the date of separation, shall be required to repay the entire amount of the buyout. Under certain circumstances, employees may be eligible for exceptions or waivers with respect to some of the above statutory prohibitions.

CERTIFICATION
I certify that: 1. I have received a copy of Title 18 U.S.C. 207 "Restrictions on Former Officers, Employees, and Elected Officials of the Executive and Legislative Branches;" and 2. I understand that I am personally responsible for complying with all Federal conflict of interest statutes including those restrictions on post-employment activities cited above.
SIGNATURE DATE

FORM FDA 2097 (1/03)

PSC Media Arts (301) 443-1090

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