DOE F 470.5 Authorization and Consent to Release Human Reliability P

DOE F 470.5 (07/03) OMB Control No. 1910-5122

Replaces DOE F 5631.37 All other editions obsolete.

U.S. Department of Energy

OMB Disclosure Statement

Public reporting burden for this collection of information is estimated to average two minutes per response, including the 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 this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden, to Office of Security, HS-50, GTN, Paperwork Reduction Project (1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585-1290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-5122), Washington, DC 20503.

AUTHORIZATION AND CONSENT TO RELEASE HUMAN RELIABILITY PROGRAM (HRP) RECORDS IN CONNECTION WITH HRP

1. I, (print applicant’s/employee’s full name) am a candidate for occupying or continuing to occupy an HRP-identified position.

2. I understand that the HRP certification process will generate medical and non-medical records (hereinafter “HRP records”) relevant to my eligibility to occupy an HRP position. I recognize that these HRP records are protected by the Privacy Act of 1974, as amended.

3. For purposes of this consent, my HRP records include, but are not limited to, any records generated by a pre-employment check performed by either (DOE contractor’s corporate name, hereinafter “Corporation”) or the Department of Energy (DOE): medical records, including but not limited to, medical histories, results of medical examinations, results of psychological examinations and/or tests; results of urine tests taken to determine the presence of illegal drugs in my body; and the results of an alcohol breathalyzer test.

4. I hereby consent that any of the HRP records within the coverage of paragraph 3 may be disclosed to the appropriate Corporation management and DOE officials who have a legitimate need for the records in the performance of their duties and responsibilities in the HRP review and approval process.

5. I acknowledge that such disclosure in connection with the HRP is an approved disclosure in accordance with 5 USC §552a(b)(1). I further agree that this document will serve as written consent to the disclosure of the HRP records to the appropriate Corporation management and DOE officials within the meaning of the Privacy Act.

6. I further waive any rights and release the Corporation, DOE, and any and all individuals employed by the corporation or DOE, including DOE contractor medical department personnel, from liability under the Privacy Act, 5 USC §552a, the U.S. or state constitutions, any other applicable federal or state statutes, any applicable physician-patient privilege, and common law claims of any nature whatsoever, for disclosure of my HRP records to Corporation management or DOE officials with a legitimate need for the records in the performance of their responsibilities in the HRP review and certification process.

7. My signature below acknowledges that I have read and understand the foregoing authorization and consent agreement.

Date Employee (Signature)

HRP Management Official (Print Name and Signature)

Privacy Act Statement

Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE) to regulate the

possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to aid in the determination of an individual=s eligibility for an HRP certification. The information may also be provided to other agencies of the United States government for investigations that involve protection of the national security, public health and safety, or the environment. Submission of the information requested on this form is voluntary, but failure to provide the information may result in denial of an HRP certification. If DOE uses the information for purposes other than those indicated in this statement, it will provide notice of those additional purposes to persons who have submitted information on this form.