Appendix I – FAC-COR Certification Waiver Request Form

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PART A – APPLICANT IDENTIFICATION

Enter the required following information:

Name (Last, First, Middle Initial) ____________________________________________  

E-mail Address __________________  Phone _____________  Fax ______________

Organization Name ____________________________________________

Organization Address   __________________________________________

Title, Series, Grade    ___________________________________________   

What type(s) of contract(s)/project(s) will you be managing?

□ Information Technology
□ Construction
□Advanced Research and Development
□ Other (Please Specify): _____________________________________

□ I am applying for FAC-COR Level I Waiver
□ I am applying for FAC-COR Level II Waiver
□ I am applying for FAC-COR Level III Waiver

Previously held FAC-COTR □, FAC-C □, and/or FAC-P/PM □ certification(s) from another Federal agency (Attach a copy of certification):

• Name of Agency:_______________________________________
• Date Certification Issued:________________________________

PART B – WAIVER REQUEST TYPE

Indicate the type of waiver requested by checking the appropriate blocks:

1.  q Up to 6 months – enter waiver period requested: ____________________
□ Level I       □ Level II    □ Level III

2. q Up to 1 year – enter waiver period requested: ______________________
□ Level I       □ Level II    □ Level III

PART C – RATIONALE FOR NOT ACHIEVING CERTIFICATION

Explain fully why you do not meet the certification requirements or why you cannot submit the required application for certification.  Please detail what actions you have taken to achieve certification after being assigned to an applicable project or program. Attach additional sheets, if necessary. 

PART D – PLAN TO ACHIEVE CERTIFICATION REQUIREMENTS

 Provide details of how you plan to meet or document the achievement of certification requirements within the waiver period requested. Indicate the date that you expect to achieve each certification. Attach additional sheets, if necessary.

PART E – SIGNATURES

 1. Applicant’s certification:

I certify that the information provided is accurate, current, complete, and fully supports the waiver action requested.

Applicant’s signature ________________________________Date_______________

2. Immediate supervisor’s concurrence/non-concurrence:

 I have reviewed and discussed with [applicant’s name] the waiver request and the information provided in support thereof. Based on the information provided, I

□  concur with the waiver request □ do not concur with the waiver request
□  Rationale for non-concurrence, if applicable: 

Typed or printed name _____________________________________________________
Signature _________________________________          Date ______________________

3. STAFFDIV/OPDIV Acquisition Career Manager concurrence/non-concurrence:

 I have reviewed the waiver request and the information provided in support thereof. Based on the information provided, I

□  concur with the waiver request     □  do not concur with the waiver request
□  Rationale for non-concurrence, if applicable: 

Typed or printed name ______________________________________________________
Signature _________________________________          Date _______________________

4. STAFFDIV/OPDIV Executive Officer concurrence/non-concurrence:

I have reviewed the waiver request and the information provided in support thereof. Based on the information provided, I

□  concur with the waiver request      q  do not concur with the waiver request
□  Rationale for non-concurrence, if applicable: 

Typed or printed name _____________________________________________________
Signature _________________________________          Date ______________________

5. Departmental Acquisition Career Manager Review & Tracking:

□  I have reviewed this waiver request and the information provided in support thereof.

Typed or printed name _________Judith Button_________________________________
Signature _________________________________          Date ______________________

6. HHS Senior Procurement Executive (SPE) concurrence/non-concurrence:

q I approve the waiver request       q I do not approve the waiver request
q Rationale for disapproval, if applicable: 

Typed or printed name of SPE: __Angela Billups, Ph.D._________________________
Signature _________________________________    Date ______________________

Links to the FAC-COR Handbook:

• FAC-COR Handbook (PDF-53 pages)
  • Executive Summary of the FAC-COR Handbook
  • Chapter 1: Implementation of HHS’ FAC-COR Program
  • Chapter 2: Requirements and Performance Accountability
  • Chapter 3: Application and Certification Procedures
  • Chapter 4: Certification Management
    • Appendix A: HHS’ COR Responsibilities
    • Appendix B: FAI’s Key Competencies for CORs
    • Appendix C: FAC-COR Curriculum Guidance
    • Appendix D: FAC-COR Guidance on Meeting Requirements for Continuous Learning Points
    • Appendix E: FAC-COR Appointment Letter Template
    • Appendix F: FAC-COR Certification Action and Training Request Form
    • Appendix G: FAC-COR Functional Experience Transcript Form
    • Appendix H: FAC-COR Certification through Fulfillment Form
    • Appendix I: FAC-COR Certification Waiver Request Form