Form DOE F 531 DOE F 531 Privacy Act Information Request

OMB Control No. 1910-1700
Exp. Date XX/XX/XXXX
OMB Disclosure Statement on Back

DOE F 531
(08/2013)
Replaces DOE F 1800.1 (11/1996)
All Other Editions are Obsolete

U.S. DEPARTMENT OF ENERGY

PRIVACY ACT INFORMATION REQUEST
(NOTE: Use of this form is recommended, but is not mandatory)
To request Information or Action under the Act, complete appropriate Items in Part I. and establish identity in accordance with instructions on Reverse Side. Retain copy; submit
original to the appropriate Privacy Act Officer at the U.S. Department of Energy Headquarters or Field location. . Fax PA Form to 202-586-8151 Attention: Privacy Act Office.
NOTE: Records will be provided in CD format unless otherwise stated. Part II is For Agency Use Only. FALSE STATEMENTS SUBJECT TO CRIMINAL PENALTIES.
PLEASE SEE REVERSE SIDE.
(Please Print)

PART I - REQUESTER (Please Print)
Full name of requester:

Requester’s Relationship to the individual who is the subject of the
records (Representatives are: Parent of a minor; legal guardian,
or representative authorized by the individual.

Name of individual whose record(s) are requested:

Requester’s Shipping Address:

Action Requested:
Access
Amendment
Copies
Correction
Program Office, Staff Office, Field Site or Lab that you are
requesting records from:

Requester’s Telephone No.: (Include Area Code):

Date of Request:

Requester’s Email:

Check the type of records you are requesting:
Medical

Personnel Records

X-Ray Reports

Radiation Exposure Report

Occupational and Industrial Records

Other

If “other” is checked, please describe the type of records you are requesting:

Give any identifying data that would help locate the record (e.g.,
maiden name, occupational license number, time and place of
employment, etc.):

Request Description:

To verify my identity for Privacy Act purposes:
I have completed and signed this form;
I have enclosed a copy of two documents containing my name and signature, one of which contains my current address and
date of birth , such as a driver’s license, passport, or voter registration card, etc. or;
I have provided in person, a copy of a document containing my photograph and signature; or two documents containing my
name and signature, one of which contains my current address and date of birth, such as a driver’s license, passport, or voter
registration card, etc. or;
I am a representative authorized by the individual whose records are being requested. I have submitted a notarized authorization
letter indicating the individual has given permission to act on their behalf.
Requester’s Signature:

PART II - FOR AGENCY USE ONLY
Proof of Identity established in person
before: (Name, Title, Location):

Received by:

Fee data:

Date request received:

Amount due: $

Action assigned to:

Date received:

Date:
Non-collectable costs:
Due Date of Response to Requester:

Copy Distribution: Requester keeps copy; sends original to the Department of Energy

OMB Disclosure Statement
Public reporting burden for this collection of information is estimated to average .33 hour per response, including the time for reviewing
instructions. Send comments regarding this estimate or any other aspect of this information, including suggestions for reducing this
burden, to Office of the Chief Information Officer, Records Management Division, IM-23, U.S. Department of Energy, Washington, DC
20585; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-1700), Washington, DC
20503.

Section 5 USC 552a (i) - Criminal Penalties
(1) Any officer or employee of an agency, who by virtue of his employment or official position, has
possession of, or access to, agency records which contain individually identifiable information the
disclosure of which is prohibited by this section or by rules or regulations established there under,
and who knowing that disclosure of the specific material is so prohibited, willfully discloses the
material in any manner to any person or agency not entitled to receive it, shall be guilty of a
misdemeanor and fined not more than $5,000.
(2) Any officer or employee of any agency who willfully maintains a system of records without meeting
the notice requirements of subsection (e) (4) of this section shall be guilty of a misdemeanor and
fined not more than $5,000.
(3) Any person who knowingly and willfully requests or obtains any record concerning an
individual from an agency under false pretenses shall be guilty of a misdemeanor and fined
not more than $5,000.
OTHER PENALTIES
A person who falsely or fraudulently attempts to obtain records under the Privacy Act, Title 5 U.S.C.
Section 552a, may also be subject to prosecution under other criminal statutes such as 18 U.S.C.
494,495, and 1001.
Establishing Valid Identification of Individual Making Request Under the Privacy Act
Pursuant to Title 10, Code of Federal Regulations, Section 1008.4 (b)(1) and (b)(2), an individual
making a request may establish identity by:
(1) Including with the request, if submitted by mail, a photocopy of two identifying documents bearing
name and signature, one of which shall bear current home or business address and date of birth; or
(2) Appearing at the appropriate DOE Headquarters or Field location during business hours and
presenting either of the following:
(i) One identifying document bearing photograph and signature; or
(ii) Two identifying documents bearing name and signature, one of which shall bear current home
or business address and date of birth.
Privacy Act Statement
Title 5 U.S.C. Section 552a(b) and (d) authorizes collection of this information. The information is
used to authorize agency personnel to locate and review records which are located in a system
of records established under the Section.