SF-85PS Supplemental Questionnaire for Selected Positions

Standard Form 85PS
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No. 3206 0005
NSN 7540-01-368-7778
86-111

SUPPLEMENTAL QUESTIONNAIRE FOR
SELECTED POSITIONS

Instructions
This form is supplemental to the SF 85P, Questionnaire for Public Trust Positions. This form
has the same purposes, authorities, and Privacy Act Routine Uses, described on the SF
85P. The agency which gave you this form will tell you which questions to answer.
Instructions for completing this form are the same as the SF 85P. Type or legibly print your
answers in ink (if the form is not legible, it will not be accepted). Be sure to sign and date the
certification statement at the bottom of this page.

PUBLIC BURDEN INFORMATION: Public burden reporting for this collection is 20 minutes,
including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to OPM Forms
Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Washington DC 20415.
Do not send your completed form to this address, send it to the office that provided you
the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect
this information, and you are not required to respond, unless this number is displayed.

1 IDENTIFICATION INFORMATION
2 SOCIAL SECURITY NUMBER

FULL NAME Enter your name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions
Last name

Middle name

First name

Jr.,II, etc.

YES

3 MENTAL AND EMOTIONAL HEALTH

NO

Mental health counseling in and of itself is not a reason to revoke or deny a clearance.
In the last 7 years, have you consulted with a health care professional regarding an emotional or mental health condition or were you hospitalized for such
a condition? Answer "No" if the counseling was for any of the following reasons and was not court-ordered:
1) strictly marital, family, grief not related to violence by you; or
2) strictly related to adjustments from service in a military combat environment.
If you answered "Yes," indicate who conducted the treatment and/or counseling, provide the following information, and sign the Authorization for Release of Medical Information
Pursuant to the Health Insurance Portability and Accountability Act (HIPAA).
Dates of Treatment and/or Counseling
Month/Year To Month/Year

Name/Address of Provider

State

ZIP Code

#1
#2
4 ILLEGAL USE OF DRUGS OR DRUG ACTIVITY
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your
failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information
derived from your responses will be used as evidence against you in any subsequent criminal proceeding.

a

In the last 7 years, have you illegally used any controlled substance, for example, cocaine, crack cocaine, THC (marijuana, hashish, etc.),
narcotics (opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed, crystal methamphetamine, Ecstacy, ketamine, etc.),
depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants (toluene, amyl nitrate,
etc.) or prescription drugs (including painkillers)? Use of a controlled substance includes injecting, snorting, inhaling, swallowing,
experimenting with or otherwise consuming any controlled substance.

b

Have you EVER illegally used a controlled substance while possessing a security clearance; while employed as a law enforcement officer,
prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety?

c

In the last 7 years, have you been involved in the illegal possession, purchase, manufacture, trafficking, production, transfer, shipping,
receiving, handling, or sale of any controlled substance (see question a above) including prescription drugs?
In the last 7 years, have you received counseling or treatment or have you been ordered, advised, or asked to seek counseling or treatment
as a result of your use of drugs? If you answered "Yes," provide date(s) of treatment and name(s) and address(es) of provider(s). You will
be asked to sign an additional release if information is needed concerning any treatment.

d

YES

NO

If you answered "Yes" to a-d above, provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity.
Dates of Use/Activity
Month/Year
To
Month/Year

Type of Controlled Substance(s)

Explain (nature of use/activity, frequency of activity, and number of times used)

#1
#2
5 USE OF ALCOHOL

YES

Respond for the timeframe of the last 7 years.

a

Has your use of alcohol had a negative impact on your work performance, your professional or personal relationships, your finances, or
resulted in intervention by law enforcement/public safety personnel? (If "Yes," explain.)

b

Have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol?

c

Have you received counseling or treatment as a result of your use of alcohol?

NO

If you answered "Yes" to question b or c above, provide the date(s) of treatment and the name(s) and address(es) of the counselor(s) or doctor(s) below. Do not
repeat information reported in response to Question 3. You will be asked to sign an additional release if information is needed concerning any treatment.
Month/Year

To

Month/Year

Name/Address of Counselor or Doctor

State

ZIP Code

#1
#2

CERTIFICATION
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I have carefully read
the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C.
1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my employment prospects or job status up to and
including my removal and debarment from Federal service.
Signature (Sign in ink)
Date (mm/dd/yyyy)

Standard Form 85PS
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
SELECTED POSITIONS

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

If you answered "Yes" to Question 3, carefully read this authorization to release information about you, then sign and date it in ink.

Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) the questions below concerning your mental health
consultations. Your signature will allow the practitioner(s) to answer only these questions.
Authorization
I am seeking assignment to or retention in a position of public trust with the Federal Government. As part of the clearance
process, I hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal
agency conducting my background investigation, to obtain the following information relating to my mental health
consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to the U.S.
Office of Personnel Management. I understand that I may revoke this authorization except to the extent that action has
already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment,
payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
I understand the information disclosed pursuant to this release is for use by the Federal Government only for purposes
provided in the Standard Form 85PS and that it may be disclosed by the Government only as authorized by law, but will no
longer be subject to the HIPAA privacy rule.
Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed
or upon termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)

Full name (Type or print legibly)

Date signed (mm/dd/yyyy)
Social Security Number

Other names used
Current street address

Apt. #

City (Country)

State

ZIP Code

Home telephone number

For Use By Practitioner(s) Only
Does the person under investigation have a condition that could impair his or her judgment or reliability?
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.

What is the prognosis?

Signature (Sign in ink)

Practitioner name

Date signed (mm/dd/yyyy)