Please indicate the type of Special Salary Rate request by checking the appropriate box(es) below:

Request to be excluded from an initial request or from an existing authorization.
Complete items I and VI-B

Initial request/termination/review other than annual.

Initial request for Special Salary Rates.  Complete items I through VI-A.  Do not do item VII, salary comparisons, unless specifically required by OPM.

Out-of-cycle review of existing authorization.   Follow instructions for initial request.

Terminate an existing authorization.  Complete items I and VI-B.

Annual review of existing authorizations where increase requested is:

Equal to the General Schedule increase.  Complete items I and VI-A; also fill in Total Positions in item II, Ending Snapshot.

Less than the General Schedule increase.  Complete items I and VI-A; also fill in Total Positions in item II, Ending Snapshot.

Greater than the General Schedule increase.  Follow instructions for initial request.

No increase, and reduce current schedule.  Complete items I and VI-B; also fill in Total Positions in item II, Ending Snapshot.

For existing authorizations, please enter the Special Salary Rate Table Number

Note: It may be possible to make the pay comparisons for this request using off-the-shelf salary surveys. If so, there will be no requirement to conduct a salary survey as part of this submission. Agencies may save time and effort by contacting OPM on the salary survey matter before a request is formally submitted.

Name of submitting agency:

Location:

Name of preparer:

Telephone:

Date prepared:

I - COVERAGE.

For existing authorizations,  if there is no change in coverage, it is not necessary to complete item I.  Please be sure that the existing special salary rate table number is entered on the front page of this form.

A. OCCUPATION(S):

Please enter the occupation series code and job title for each occupation to be covered by this request.
Attach a separate sheet if more room is required.

B. AGENCIES/GEOGRAPHIC LOCATIONS:

Please enter the code and name of each agency and subelement having positions to be covered by this request. Specify geographic location codes for all but Nationwide or Worldwide authorizations. If an entire MSA/PMSA is to be covered, give only the 4-digit MSA/PMSA code for each area (see note below.) If an entire CMSA is to be covered, simply give the official CMSA name; no code is required. Attach a separate sheet if more room is required.

II - STAFFING STATUS

The staffing data presented on this page should represent a snapshot of your staffing situation at two specific times, the beginning date and the ending date.

If more than one agency is involved in this request, the OPM-designated lead agency should aggregate all staffing, recruitment, and turnover data (i.e., summed for all agencies for each category and grade).

All numbers should be current to within 60 days of submission, if possible.

Definitions of categories (At beginning date/ending date):

On Board

Total filled positions in the grade and occupation, at that time.

Vacant Positions

Total positions you were trying to fill in the grade and occupation, at that time, with appropriate authority and funding.

Total Positions

The sum of the on board and vacant positions, at that time.

Beginning Date           /          /         

Ending Date           /          /         

III - RECRUITMENT AND TURNOVER

The data presented on this page should represent recruiting and turnover that occurred during the entire reporting period as defined by the beginning snapshot date (See Item II, page 3 of this form).

The OPM-designated lead agency should aggregate data for all agencies involved in this request.

Definition of categories:

Recruitment during the period:

Positions Tried to Fill

Number of vacancies the agency tried to fill, with appropriate authority and funding.

Offers Made

The number of bona fide offers of employment made to persons within and outside the Federal Service, under any appointing authority, who met all pre-employment screening required by your agency.

Number Hired

The total number of persons hired by your agency in the occupations and grades covered.

Turnover during the period:

Losses

Total number of losses to the grade, for all reasons, which resulted in a recruiting action.

Quits

Total number of employees who left Federal employment and whose loss resulted in a recruiting action.

Quits for Pay

Total separations of persons leaving Federal service to take an equivalent position outside the government, in the same occupation and location, because the salary is higher.

Recommended Salary

is the agency's requested new special salary rate for the first step of each grade covered. The recommended salaries do not have to correspond to current General Schedule steps.

Current Salary

should be the first step of the current General Schedule or the first step of the current Special Salary Rate Schedule for each grade covered by this request.

Added Salary

is the difference between the recommended salary and the current salary.

Total Positions

are the Total Positions from the Ending Snapshot, Item II, page 3 of this form.

Added Costs

are Added Salary multiplied by Total Positions.

Total Added $

is the sum of the Added Costs column.

Formula:       [recommended  salary] -    [current salary] =  [added salary]   H    [total positions]     =    [added costs]  

GS Grade

Recommended Salary

Current Salary

Added Salary

Total Positions

Added Costs

Total Added $

A. Why are special salary rates needed? Please check at least one reason and as may others that apply to this specific situation.

Private Sector Pay
Other Federal Gov't Pay
Local Gov't Pay
Undesirable Working Conditions
Nature of Work
Other Reasons (please explain)

B.  Please estimate costs attributable to the staffing situation which would be offset if this special salary rate request is approved.

Overtime
Contracting
Training
Other (please explain)

VI-A CERTIFICATION FOR INCREASE

Please use this certification for all requests that involve the initial granting of special salary rates or an increase to an existing authorization. The OPM-designated lead agency should collect and attach certifications for each agency involved in this request. Type the name of the certifying official in the blank space provided in the text of the certification.

I,                                                           , certify that the special rates requested are necessary to ensure staffing adequate to accomplish the agency's mission. This agency has made all possible efforts to overcome the staffing problems in other ways, including use of some or all of the recommended techniques such as job redesign, improvement of working conditions, skills improvement, direct hire authority, OPM delegation of examining authority, above-minimum entry rates, recruitment bonuses and retention allowances.

Position of certifying official                                                                            Agency Name                                                                      

Signature of certifying official                                                                                                                                    

Date               /               /              

VI-B REQUEST FOR TERMINATION/REDUCTION/EXCLUSION

Please use the appropriate certification to request termination or reduction of an existing special salary rate authorization or to be excluded from either a new request or an existing authorization.  If termination or reduction is requested and more than one agency is covered by this authorization, all must agree to its termination or reduction, and so certify.

I,                                                                , certify that the special salary rate authorization specified in Special Salary Rate Table

Number                 is no longer required by this agency to alleviate a staffing problem.  Termination of the authorization is hereby requested.

I,                                                                , certify that a special salary rate authorization specified in Special Salary Rate Table

Number                 is no longer required at the same level.  Reduction of the rates is hereby requested.

I,                                                                , certify that this agency wishes to be excluded from:

Position of certifying official                                                                            Agency Name                                                                      

Signature of certifying official                                                                                                                                                                   

Date               /               /              

Please use this worksheet to aggregate the data from all Part 1 worksheets

1. Enter the GS grade in the first column below.

2. Transfer the Totals from Part 1 worksheet for each grade as follows:

From Part 1, Column:

C

E

F

H

J

K

M

N

To Part 2, Column:

P

O

S

R

U

V

X

W

3. Compute columns Q, T, and Y, Weighted Averages, as follows:

Column          =       Column          +       Column

Q

O

P

T

R

S

Y

W

X

4. Please check all computations. Send all worksheets to OPM.

Formula:               O        +        P       =      Q                   R         +        S          =         T                                                        W       +       X        =        Y