Form FD-961 BIOTERRORISM PREPAREDNESS ACT: ENTITY/INDIVIDUAL INFORMA

INSTRUCTIONS

The FD-961 Form can be obtained by accessing the Criminal Justice Information Services Division web page at www.fbi.gov/hq/cjisd/cjis.htm. Click on the Bioterrorism link located at the bottom of the page. The FD-961 form can be completed on line, printed and mailed with the fingerprint cards as a complete package to the CJIS Division (First Time Applicant). Or the FD-961 form can be completed on line, printed and faxed to the CJIS Division at 304-625-5393 (Renewal, Repeat, and Reactivations). The fingerprint card packages consists of two fingerprint cards, general instructions, fingerprint instructions, and a pre-addressed return envelope. These packages can be obtained via faxing a request to the FBI at 304-625-3984. The faxed request should include the following: the entity name, point of contact or RO, the correct mailing address, contact telephone number and how many fingerprint card packets are requested. In order for the security risk assessment to be processed in a timely manner, the FD-961 Form and two legible fingerprint cards must be returned to the FBI as one package. The FBI will not conduct a security risk assessment for an individual unless it has received a completed FD-961 Form and two legible fingerprint cards. For questions concerning who needs to complete the FD-961 form please reference the Frequently Asked Questions posted on the Select Agent web page at www.cdc.gov/od/sap/faq.htm.

GENERAL GUIDANCE ON COMPLETING THE FD-961 FORM:

Section I, Block 1: Provide the legal name of the entity and the entity application number supplied by APHIS or CDC.

Section I, Block 3: Indicate the type of applicant by following the guidelines below:

First Time Applicant: Individual acquiring access to select agents and toxins. Requires completed FD-961 form with DOJ Number and two fingerprint cards submitted to the CJIS Division.

Renewal Applicant: Individual working at the same entity for the 3 – 5 year renewal time frame. Requires completed FD-961 form with DOJ Number submitted to the CJIS Division.

Repeat Applicant: Individual acquiring access to select agents and toxins at a different entity than originally cleared for. Requires completed FD-961 form with DOJ Number submitted to the CJIS Division.

Reactivation Applicant: Individual who in the past had access to select agents and toxins but resigned or withdrew from the program. Requires completed FD-961 form with DOJ Number submitted to the CJIS Division.

Section II:

1. Block 4: Include full name (last, first, middle, and suffix, e.g. Jr. or III) . The name provided in block 4 should be identical to that indicated on Table 4B of CDC Form APHIS/CDC Form 1.

2. Block 4a: Include any Aliases/Maiden names.

3. Block 11: Ensure the unique identifying number supplied by APHIS or CDC for the individual is provided. CDC or APHIS will provide to the RO a unique identifying number for each individual listed on Table 4B of CDC Form APHIS/CDC Form 1. Information about how to obtain a DOJ number is available on the Internet at http://www.aphis.usda.gov/programs/ag_selectagent/index.html or http://www.cdc.gov/od/sap.

4. Block 12a - 12h: Answer all questions located in blocks 12 a-h with a "yes" or "no" in the boxes provided.

5. Questions concerning completion of the FD-961 Form can be directed to the Bioterrorism Help Line at 304-625-4900.

COMPLETION OF FINGERPRINT CARDS:

First time applicants will be provided with two fingerprint cards to have printed by a local law enforcement agency. Individuals or entities must arrange for this service. In most instances the law enforcement offices will charge a fee for this service. The two fingerprint cards and the completed FD-961 Form must be submitted to the FBI in the provided envelope in order to process the security risk assessment. The FBI may request a second set of prints to process in the event that the initial two fingerprint cards are rejected from the Integrated Automated Fingerprint Identification System for image quality.

Once printed, the two fingerprint cards and the completed FD-961 Form must be forwarded to the FBI. In order for the security risk assessment to be processed in a timely manner, the FD-961 Form and Fingerprint Cards must be returned to the FBI as one package mailed in the pre-addressed envelope. If not using the pre-addressed envelopes please submit completed packages to:

Bioterrorism Security Risk Assessment Group E-3

CJIS Division

1000 Custer Hollow Road

Clarksburg, WV 26306-0002

The FBI will not conduct a security risk assessment for an individual unless it has received a completed FD-961 Form and two legible fingerprint cards.

Additional Requirements: Under any case where an individual is changing employers, reactivating employment or completing a security risk assessment renewal, the individual must submit a completed FD-961 form to the FBI via mail or fax. Two fingerprint cards are not required if a legible set is already on file with the FBI. The FBI reserves the right to request additional fingerprint cards in the future if necessary. A full security risk assessment must be completed prior to an individual being granted access to select agents and toxins at the new place of employment. The security risk assessment granted under previous employment is NOT transferrable.

PRIVACY ACT STATEMENT

Authority:

Collection of this information is authorized under Public Law 107-188; 18 U.S.C. § 175b; 28 U.S.C. § 534; 28 CFR § 0.85; 7 CFR Part 331; 9 CFR Part 121; 42 CFR Part 73.

Principal Purpose and Routine Uses

The information collected on this form will be used for the principal purpose of conducting security risk assessments for entities that possess, receive, use and/or transfer select agents and toxins, individuals who own or control an entity, individuals authorized to have access to select agents or toxins, and responsible officers. As part of this assessment, the collected data may also be used to assist in determining approval, denial, revocation or renewal of a certificate of registration issued by Department of Health and Human Services (HHS) or U.S. Department of Agriculture (USDA) for possession, use and transfer of select agents and toxins.

Additionally, information provided in all or part of this completed form may be disclosed to Department of Justice personnel who need the information in the performance of their duties and outside the Department of Justice to HHS and/or USDA for the purpose of making security risk assessments and other determinations relating to individuals, entities and responsible officers that have access to or possess, use, receive and/or transfer select agents and toxins; to federal, state, local, joint, tribal, foreign or international entities charged with the responsibility of investigating, prosecuting, and/or enforcing laws, regulations, rules, orders or contracts if any part of the information received, either on its face or in conjunction with other information, indicates a violation or potential violation of law, regulation, rule, order, or contract; to any law enforcement or intelligence authority or other federal, state or local entity with relevant jurisdiction where such information reveals a risk to human, animal and/or plant health or national security; to organizations or individuals, both public and private, if deemed necessary, in the sole discretion of the U.S. Department of Justice, to elicit information or cooperation from the recipient for use in assessing suitability to access, possess, use, receive or transfer select agents and toxins; and pursuant to the routine uses most recently published in the Federal Register for the FBI's Central Records System (Justice/FBI-002) and the FBI's Blanket Routine Uses (Justice/FBI-BRU).

Social Security Account Number

Your Social Security Account Number (SSAN) is requested under Public Law 107-188, 7 CFR Part 331, 9 CFR Part 121 and 42 CFR Part 73, which authorize the Attorney General to collect names and other identifying information in the security risk assessment process and to check criminal, immigration, national security and other electronic databases. Because other people may have the same name and birth date, your SSAN will be used to facilitate accurate identification and to help eliminate the possibility of misidentification of individuals for whom a security risk assessment or database check is being conducted.

Effects of Nondisclosure

Completion of this form and provision of your SSAN is voluntary. However, failure to provide the requested information may result in a finding that you may not have access to a select agent or toxin because of an incomplete application or an unapproved security risk assessment.

PAPERWORK REDUCTION ACT NOTICE

The information required on this form is in accordance with the Paperwork Reduction Act of 1995. The purpose of this information is to assist the FBI in national security risk assessments for entities and individuals having access to selected toxins as required by the Public Health Security and Bioterrorism Preparedness Response Act of 2002.

The estimated average burden associated with this collection of information is 45 minutes, depending on circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to Federal Bureau of Investigation, Bioterrorism Security Risk Assessment Mod E-3, Criminal Justice Information Services Division, 1000 Custer Hollow Road, Clarksburg, WV 26306.

FD-961 (Rev. 01-12-09) OMB No. 1110-0039 - Exp 2012

FEDERAL BUREAU OF INVESTIGATION

BIOTERRORISM PREPAREDNESS ACT: ENTITY / INDIVIDUAL INFORMATION

Title 18 Section 1001 of the U.S. Code provides that knowingly falsifying or concealing a material fact is a felony that may result in fines or imprisonment for not more than 5 years or both.

Section I: Entity Information

1. Legal Name of Entity and Entity Application Number (Supplied by APHIS or CDC) :

2. Address: Street City County State Zip Code

3. Type of Applicant:

□ First Time Applicant □ Repeat Applicant

□ Renewal Applicant □ Reactivation Applicant

Section II: Individual Information

4. Full Name (Last, First, Middle) 4a. Aliases/Maiden Name:

5. Date of Birth (Month, Day, Year)

6. Social Security Number

7. Residence Address: (Number, Street, City, State, Zip Code)

8. Sex: □ Male □ Female

9. Place of Birth (City, State or Foreign Country) IF NOT BORN IN THE UNITED STATES PLEASE COMPLETE QUESTIONS ON PAGE 2 TITLED FOREIGN BORN INFORMATION.

10. Race: □ White □ Black or African □ Hispanic or Latino □ Asian/ Native Hawaiian □ American Indian or other Pacific Islander Alaska Native

11. DOJ Number (Supplied by APHIS or CDC):

12. Certifications (All questions must be answered "Yes" or "No" in the box provided)

12a. Are you under indictment or information in any court for a felony or any crime for which the judge could imprison you for more than one year? □ Yes □ No

12b. Have you been convicted in any court for a crime for which the judge could have imprisoned you for more than one year even if you received a shorter sentence including probation? □ Yes □ No

12c. Are you a fugitive from justice? □ Yes □ No

12d. Are you an unlawful user of any controlled substance (as defined in Section 102 of the Controlled Substance Act [21 U.S.C. 802] )? □ Yes □ No

12e. Have you ever been adjudicated as a mental defective or been committed to any mental institution? If yes, a complete copy of medical records regarding the commitment will be required. □ Yes □ No

12f. Are you an alien illegally or unlawfully in the United States? □ Yes □ No

12g. Are you an alien who has been lawfully admitted for permanent residence or a naturalized citizen? IF NOT BORN IN THE US PLEASE COMPLETE QUESTIONS ON PAGE 2 TITLED FOREIGN BORN INFORMATION. □ Yes □ No

12h. Have you been discharged from the Armed Services of the United States under dishonorable conditions? □ Yes □ No

I certify that the above answers are true, correct and complete. I understand that the making of a false oral or written statement is a crime. Signature

Date:

Foreign Born Information

This page must be completed by any individual answering “YES” to question 12g of page 1. All questions MUST be answered. Be sure to include all alien or admission numbers for question 9.

13. Country of Citizenship:

14. Mother’s Full Maiden Name:

15. Father’s Full Name:

16. Date of Entry to the United States:

17. Place of Entry:

18. Immigration Status at Entry:

19. Current Immigration Status:

20. Date Status Expires, if Applicable:

21. Alien registration numbers are issued by the Bureau of Immigration and Customs Enforcement for individuals who are granted permanent legal resident or a naturalized citizen status in the U.S. Other situations that individuals would have an alien registration number include the following: Employment Authorization cards, Temporary Resident cards, Border Crossing cards, I-94 or Visa numbers. If this number is not available please provide an explanation. If born to US citizen serving a military or diplomatic post in a foreign country please provide a copy of the US born abroad birth certificate. IF THE ALIEN NUMBER OR ADMISSION NUMBER IS NOT PROVIDED A SECURITY RISK ASSESSMENT WILL NOT BE COMPLETED.

Alien Number or Admission Number (9-11 digits):

Consent

Section III:

By signing this form, I hereby authorize the U.S. Department of Justice to obtain any information relevant to assessing my suitability to access, possess, use, receive or transfer select agents and toxins from any relevant source, including, but not limited to, individuals, public sources, and government sources. This information may include, but is not limited to, biographical, financial, law enforcement and intelligence information.

I further authorize any individuals having information pertinent to such an assessment to release such information to a duly accredited representative of the U.S. Department of Justice. The authorization set forth in this paragraph is valid for five (5) years from the date on which this form is signed.

I further authorize the U.S. Department of Justice to disclose any records, results or information relating to, or obtained in connection with, my security risk assessment to: the U.S. Department of Agriculture; the Department of Health and Human Services; any agency contractors assisting in the determination of risk; and responsible officers or other appropriate personnel of pertinent entities.

I further authorize the release of records, results or information relating to, or obtained in connection with my security risk assessment to any law enforcement or intelligence authority or other federal, state or local entity with relevant jurisdiction where such information reveals a risk to human, animal and/or plant health or national security.

I further authorize disclosure of records results or information relating to, or obtained in connection with my security risk assessment to organizations or individuals, both public and private, if deemed necessary, in the sole discretion of the U.S. Department of Justice, to elicit information or cooperation from the recipient for use in assessing my suitability to access, possess, use, receive or transfer select agents and toxins.

I further authorize release of records, results or information relating to, or obtained in connection with my security risk assessment to laboratories, universities, individuals, or other entities, both public and private, responsible for making security assessments, employment and/or licensing determinations and suitability or security decisions when the information is relevant to an assessment of my suitability to access, possess, receive, use, or transfer agents or toxins

I understand that this is a legally binding document and false statements provided by me are violations of federal law and may lead to criminal prosecution or other legal action.

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PRINTED NAME DATE

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