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- Form CT-HR-10 "Certification for Psa With Current State Employee" - Connecticut
Form CT-HR-10 "Certification for Psa With Current State Employee" - Connecticut
What Is Form CT-HR-10?
This is a legal form that was released by the Connecticut State Department of Administrative Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.
Form Details:
- The latest edition provided by the Connecticut State Department of Administrative Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form CT-HR-10 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Administrative Services.
![Form CT-HR-10 "Certification for Psa With Current State Employee" - Connecticut](https://data.templateroller.com/pdf_docs_html/1763/17632/1763202/page_1_thumb.png "Form CT-HR-10 "Certification for Psa With Current State Employee" - Connecticut")
1![Form CT-HR-10 "Certification for Psa With Current State Employee" - Connecticut, Page 2](https://data.templateroller.com/pdf_docs_html/1763/17632/1763202/page_2_thumb.png "Form CT-HR-10 "Certification for Psa With Current State Employee" - Connecticut, Page 2")
2Certification for PSA with Current State Employee
Form CT-HR-10
Instructions:
•
The agency that seeks to enter into a Personal Service Agreement (“PSA”) with a current State employee
(“Contracting Agency”) must complete Section One of this form.
•
The Contracting Agency shall keep a copy of the form in a suspense file and forward the original to the agency that
currently employs the Contractor/State employee (“Employing Agency”).
•
Once the Employing Agency completes Section Two of this form and returns it to the Contracting Agency, the
Contracting Agency must complete Section Three and have the Contractor/State employee complete Section Four.
•
The Contracting Agency must maintain the fully-executed original of this form as an Addendum to the final PSA.
SECTION ONE: To be Completed by the CONTRACTING AGENCY
State Employee/Contractor’s Name:
State Employee Number:
State Employee/Contractor’s Home Address:
Today's Date:
Name and Address of Employing Agency:
Name and Address of Contracting Agency:
PSA Number:
Term of PSA:
Services to be performed under the PSA:
Time Requirements Anticipated to Perform PSA Services (including days/hours, if applicable):
SECTION TWO: To be Completed by the EMPLOYING AGENCY
Instructions: Complete and return original to Contracting Agency listed above. Retain a copy for the Employing
Agency’s files.
State Employee’s/Contractor’s Position Title with Employing Agency:
Duties Performed:
Current Work Schedule
Day
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Time In:
Time Out:
EMPLOYING AGENCY CERTIFICATION
I certify that:
•
The services to be provided under the PSA are separate and distinct from the duties and responsibilities that the
Contractor/State employee performs at this agency;
•
Performing the services under the PSA would not impair the Contractor/State employee’s independence of judgment
with regard to his/her duties at this agency, would not induce him/her to disclose confidential information learned
during the course of his/her employment at this agency, and would not otherwise create an actual or potential conflict
of interest; and
Signature (Agency Head or Authorized Designee):
Title:
Date:
Certification for PSA with Current State Employee
Form CT-HR-10
Instructions:
•
The agency that seeks to enter into a Personal Service Agreement (“PSA”) with a current State employee
(“Contracting Agency”) must complete Section One of this form.
•
The Contracting Agency shall keep a copy of the form in a suspense file and forward the original to the agency that
currently employs the Contractor/State employee (“Employing Agency”).
•
Once the Employing Agency completes Section Two of this form and returns it to the Contracting Agency, the
Contracting Agency must complete Section Three and have the Contractor/State employee complete Section Four.
•
The Contracting Agency must maintain the fully-executed original of this form as an Addendum to the final PSA.
SECTION ONE: To be Completed by the CONTRACTING AGENCY
State Employee/Contractor’s Name:
State Employee Number:
State Employee/Contractor’s Home Address:
Today's Date:
Name and Address of Employing Agency:
Name and Address of Contracting Agency:
PSA Number:
Term of PSA:
Services to be performed under the PSA:
Time Requirements Anticipated to Perform PSA Services (including days/hours, if applicable):
SECTION TWO: To be Completed by the EMPLOYING AGENCY
Instructions: Complete and return original to Contracting Agency listed above. Retain a copy for the Employing
Agency’s files.
State Employee’s/Contractor’s Position Title with Employing Agency:
Duties Performed:
Current Work Schedule
Day
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Time In:
Time Out:
EMPLOYING AGENCY CERTIFICATION
I certify that:
•
The services to be provided under the PSA are separate and distinct from the duties and responsibilities that the
Contractor/State employee performs at this agency;
•
Performing the services under the PSA would not impair the Contractor/State employee’s independence of judgment
with regard to his/her duties at this agency, would not induce him/her to disclose confidential information learned
during the course of his/her employment at this agency, and would not otherwise create an actual or potential conflict
of interest; and
Signature (Agency Head or Authorized Designee):
Title:
Date:
Certification for PSA with Current State Employee
Page 2
PSA #: ________________________
SECTION THREE: To be Completed by the CONTRACTING AGENCY
I certify that:
•
The services to be provided under the PSA are separate and distinct from the duties and responsibilities that the
Contractor/State employee performs at the Employing Agency;
•
Performing the services under the PSA would not impair the Contractor/State employee’s independence of judgment
with regard to his/her duties at the Employing Agency, would not induce him/her to disclose confidential information
learned during the course of his/her employment at the Employing Agency, and would not otherwise create an actual
or potential conflict of interest;
•
The PSA was solicited and awarded pursuant to the existing statutes and rules regarding Personal Service
Agreements; and
•
The Contracting Agency will document and review the services performed and hours worked by the Contractor/State
employee under the PSA to ensure that no equipment, systems, materials, time or personnel from the Employing
Agency are used to perform the duties under the PSA.
Signature (Agency Head or Authorized Designee):
Title:
Date:
SECTION FOUR: To be Completed by the Contractor/State Employee
I certify that:
•
The services to be provided under the PSA are separate and distinct from the duties and responsibilities that I perform
at the Employing Agency;
•
Performing the services under the PSA would not impair my independence of judgment with regard to my duties at
the Employing Agency, would not induce me to disclose confidential information learned during the course of my
employment at the Employing Agency, and would not otherwise create an actual or potential conflict of interest; and
•
I will not utilize the equipment, systems, materials or personnel of the Employing Agency to perform the services or
to complete the duties required under the PSA, nor will I perform any PSA services or duties during time owed to the
Employing Agency.
Signature:
Date:
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Most popular documents
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"Vsepr Theory (Molecular Shapes) Chart"
-
DA Form 2062 "Hand Receipt/Annex Number"
-
"Zappos Kid Shoe Size Chart"
-
DD Form 2813
-
DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
DA Form 31 "Request and Authority for Leave"
-
AF Form 910 "Enlisted Performance Report (AB Thru Tsgt)"
-
DD Form 1750 "Packing List"
-
DA Form 3595 "Record Fire Scorecard"
-
DD Form 2923 "Privacy Act Data Cover Sheet"
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