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Supplemental Form Instructions · Instructions for Completing This Supplemental Form

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Supplemental Form Instructions
Instructions for Completing This Supplemental Form

OMB No. 3206-0005
Form: SF85PS

Read the following document before attempting to complete this form.

Supplemental Questionnaire for Selected Positions (SF85PS Format)
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 SF 85P.
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.
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Section 24: Mental and Emotional Health · Section Summary

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Section 24: Mental and Emotional Health
Section Summary

OMB No. 3206-0005
Form: SF85PS

Answer the following question.
Question

Yes No

In the last 7 years, have you received counseling or treatment from a mental health
professional (including a counselor, licensed social worker, psychologist, psychiatrist,
or other psychotherapist) or any other medical professional regarding an emotional or
mental condition? Answer "No" if the counseling was strictly marital, family, or grief
counseling and did not involve the prescription of medication or violence by you.

c
d
e
f
g

c
d
e
f
g

If you answered "Yes," provide a record for each treatment to report, and sign the
Authorization for Release of Medical Information Pursuant to the Health Insurance
Portability and Accountability Act (HIPAA) (provided to you after you complete this form).

Summary of Treatments
# Dates of Treatment Name of Provider
1 From (~)/(~) To (~)/(~) (~)

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Section 24: Mental and Emotional Health · Entry Details

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Section 24: Mental and Emotional Health
Entry Details

OMB No. 3206-0005
Form: SF85PS

Dates of Treatment
Date

Month/Year

From:

/

To:

/

Est./Pres.

Indicate who conducted the treatment.

Name of Provider

Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
(List)

Explain Circumstances of Treatment

Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.

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Section 25: Use of Alcohol · Section Summary

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OMB No. 3206-0005
Form: SF85PS

Section 25: Use of Alcohol
Section Summary
Answer the following question.
#

Question

Yes No

a. In the last 7 years, has your use of alcohol had a negative impact on your work
performance, your professional or personal relationships, your finances, or resulted
in contacts by law enforcement/public safety personnel?

c
d
e
f
g

c
d
e
f
g

If you answered "Yes" to question a, explain.

Explanation

Answer the following question.
#

Question

Yes No

b. 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
alcohol?

c
d
e
f
g

c
d
e
f
g

If you answered "Yes" to question b above, provide an entry for each treatment to report.
You will be asked to sign a release if information is needed concerning your treatment. Do
not repeat information reported in response to Section 24 (Mental and Emotional Health).

Summary of Treatments
# Dates of Treatment Counselor/Doctor
1 From (~)/(~) To (~)/(~) (~)

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Section 25: Use of Alcohol · Entry Details

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OMB No. 3206-0005
Form: SF85PS

Section 25: Use of Alcohol
Entry Details

Provide the dates of treatment and the name and address of the counselor or doctor.

Dates of Treatment
Date

Month/Year

From:

/

To:

/

Est./Pres.

Name of Counselor/Doctor

Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
(List)

Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.

Save

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Section 26: Use of Illegal Drugs and Drug Activity · Section Summary

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Section 26: Use of Illegal Drugs and Drug Activity
Section Summary

OMB No. 3206-0005
Form: SF85PS

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.

Answer the following questions.
#

Question

Yes No

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,
Ecstasy, ketamine, etc.), depressants (barbiturates, methaqualone, tranquilizers,
etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants (toluene, amyl nitrate,
etc.) or prescription drugs (including painkillers)? Illegal use of a controlled
substance includes injecting, snorting, inhaling, swallowing, experimenting with or
otherwise consuming any controlled substance.

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

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?

c
d
e
f
g

c
d
e
f
g

If you answered "Yes" to any question above (a-c), provide the date(s) of use or activity,
identify the controlled substance(s), and explain the use or activity.

Summary of Substance/Drug Use/Activity
# Dates of Use/Activity Type of Controlled Substance(s)
1 From (~)/(~) To (~)/(~) (~)

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Section 26: Use of Illegal Drugs and Drug Activity · Section Summary

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Section 26: Use of Illegal Drugs and Drug Activity · Entry Details

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Section 26: Use of Illegal Drugs and Drug Activity
Entry Details

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OMB No. 3206-0005
Form: SF85PS

Dates of Use/Activity
Date

Month/Year

From:

/

To:

/

Est./Pres.

Type of Controlled Substance(s)

Explain Nature of Use/Activity, Frequency of Activity, and Number of Times Used

Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.

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