INV 41 Investigative Request for Employment Data and Supervisor

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INV FORM 41 (Rev. 4/06)
U.S. OFFICE OF PERSONNEL
MANAGEMENT (5 CFR 736)

INVESTIGATIVE REQUEST FOR EMPLOYMENT
DATA AND SUPERVISOR INFORMATION
u.s. GOVERNMENT USE ONLY

UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
BOYERS, PA 16018-0618

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INSTRUCTIONS: Your name has been provided by the person identified below to assist in completing a
background investigation to help us determine this person 's suitability for employment or security
clearance. To help us make this determination, we ask that you complete all items on the back of this form
and return the form in the enclosed envelope. We send a separate inquiry to the personnel office and each
supervisor shown on the person 's application; therefore please do not forward this for completion by
someone else.
PRIVACY ACT INFORMATION: This investigative inquiry is in full compliance with the Privacy Act of 1974 and other laws
protectin g the civil rights of the person we are investigating. The information you provide, including your identity, will be
disclosed to the person beIng Investigated and other federal agencies, at this person's request.
CERTIFICATION: The person we are investigating has given written consent for this investigative inquiry. We keep that
consent on file. If a copy is required in order to complete this form , or you would like to keep your identity confidential ,
please indicate this requirement in writing on the reverse.

Completion of this investigation as soon as possible will help this person and the agency perform their duti es in a
more timely and efficient manner.
CASE NUMBER:

CASE TYPE :

ITEM NUMBER:

FULL NAME (LAST, FIRST, MIDDLE)
OTHER NAMES USED

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DATE OF BIRTH

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SOCIAL SECURITY NUMBER

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POSITION FOR WHICH INVESTIGATED

PLACE OF BIRTH
CLAIMED EMPLOYMENT
FROM

TO

POSITION

NAME OF SUPERVISOR

ACTUAL JOB LOCATION (IF DIFFERENT THAN ABOVE ADDRESS)

PUBLIC BURDEN IN FORMATION. We estlmllte the PLJb I,c Burden for this collection of onformatlon Is approxImately 5 rnnutes per respooH. This Includes tome lor reVlewlf'Ig the Instructions. galhenng the IflformalLon requested. and completong
arld ,eluming the l(l.nll You may aetlc:I cOmm&n ts ,egardmg our estImate or any ollie' aspect 01 tn.s form. includIng suggonUons lor 'educmg complellOl'1 lime. to the Office or PIII'SOMei Mllfl8ge"'lIfIt. Forms 01t'C8l. Paperwork Redl.lC(IOIl Act
(3206,0165). Wash~on. DC 20415·7900. Thfl OMB Numbll< 3200-0165 IS cumll1tty valId. OP M may nol collec:lthls IIlforma~on. and you are nolll!QULred to respond. unless tillS number Is d.spklyed. 00 not:;.end y<)Ilr completed form to til",
oadress.

G:x)' U S. GOVERNMENT PRINTING OFFICE: 2008-339-7941634101S·00 145

221431 · 3

FORM APPROVED : OMB:3206-01 65

CORRECT MARK:

• USE A NO.2 PENCIL OR BLUE OR BLACK INK PEN ONLY.
• DO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER.
• DO NOT MAKE ANY STRAY MARKS ON THIS SHEET.

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MARKING
INSTRUCTIONS

INCORRECT MARKS:

X

./

PLEASE COMPLETE THE ITEMS SHOWN BELOW

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[S THE INFORMATION ON THE FRONT OF THIS FORM THE SAME AS SHOWN IN YOUR RECORDS?

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MARK ONE OF THE FOLLOWING PERTAINING TO THIS PERSON'S EMPLOYMENT:

a
a

YES

b

NO (Please explain in item 6)

WE HAVE NO RECORD ON THIS PERSON

C

d

SUBJECT CURRENTLY EMPLOYED HERE

L EFT EMPLOYMENT VOLUNTARILY/EMPLOYMENT NOT

ENTIRELY FAVORABLE (Please explain in item 6)

b

e

LEFT EMPLOYMENT VOLUNTARILY/EMPLOYMENT

DISCHARGED FOR UNFAVORABLE EMPLOYMENT OR

ENTIRELY FAVORABLE
C

CONDUCT (Please explain in ilem 6)

f

DISCHARGED BECAUSE OF COMPANY CUTBACK IN

RESIGNED AFTER INFOAMED OF POSSIBLE

WORKFORCE OR CHANGE IN SKILL NEEDS

DISCHARGE (Please explain in item 6)

LEFT EMPLOYMENT BY MUTUAL AGR EEMENT D UE
TO SPECIFIC PROBLEMS (Please explain in item 6)

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IS THIS PERSON ELIGIBLE FOR REHIRE?

a

YES

b

NO - DUE TO COMPANY POLICY ANDIOR
NOT RELATED TO UNFAVORABLE EMPLOYMENT

NO - FOR REASONS RELATING T O UNFAVORABLE
EMPLOYMENT (Please explain in item 6)

C

DO YOU HAVE ANY REASON TO QUESTION THIS PERSON'S HONESTY OR TRUSTWORTHINESS?

a

NO

C

I DO NOT KNOW THIS PERSON WELL ENOUGH TO RESPOND

b

YES (Please explain in item 6)

d

I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

DO YOU HAVE ANY ADVERSE INFORMATION ABOUT THIS PERSON'S EMPLOYMENT, RESIDENCE OR ACTIVITIES CONCERNING:
YES NO

YES NO

YES NO

a

VIOLATIONS OF THE LAW

c

ABUSE OF ALCOHOLANDIOR DRUGS

e

GENERAL BEHAVIOR OR CONDUCT

b

FINANCIAL INTEGRITY

d

MENTAL OR EMOTIONAL STABILITY

f

OTHER MAlTERS

(If YES to any of these questions, please explain in item 6)
I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

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IF ADDI TIONAL IN FORMATION IS PROVIDED BELOW, YOU MUST FILL IN THIS MARK

ADDITIONAL INFORMATION WHICH YOU FEEL MAY HAVE A BEARING ON THIS PERSON·S SUITABILITY
FOR GOVERNMENT EMPLOYMENT OR A SECURITY CLEARANCE. THIS SPACE MAY BE USED FOR
DEROGATORY AS WELL AS POSITIVE INFORMATION.

00 YOU RECOMMEND THIS PERSON FOR GOVERNMENT SECURITY CLEARANCE OR EMPLOYMENT?

a

c

YES

I DON'T KNOW THIS PERSON WELL ENOUGH TO MAKE A RECOMMENDATION

b
NO (Please explain in item 6)
PRINT NAME:
PLEASE SIGN THIS FORM HERE:

DATE

DAYTIME TELEPHONE NUMBER

YOUR TITLE:

(I Ne~UCEAREA

eOCE)

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(

FOR OPM USE ONLY
RESULTS

ISSUES/CHARACTERIZATION

AC ACCEPTABLE

IS

ISSUES

1 0

A

B

C

D

E

N

9 0

A

B

C

D

E

AA ACCEPTABLEJATIACHED

PI

CONFIDENTIAUISSUES

2

0

A

B

C

0

E

N

A

B

C

0

E

PA CONFIDENTIAUACCEPTABLE

AI RECORD INCONCLUSIVE

3 0

A

B

C

0

E

N

10 0
11 0

A

B

C

0

E

4 0
5 0

A

B

C

0

E

N

12 0

A

B

C

0

E

A

B

C

0

E

N

13 0

A

B

C

0

E

A

B

C

0

E

N

14

A

B

C

0

E

A

B

C

0

E

N

A

B

C

0

E

N

NI NO PERTINENT INFORMATION

FA FEE REQUIRED

NR NO RECORD

RL RELEASE REQUIRED

NL NOT LOCATED

SK SUBJECT UNKNOWN

uc UNABLE TO CONTACT

NZ NOT AVAILABLE

6 0
7 0

RF REFERRED

ON DISCREPANT

8 0

RR RECORD

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0

N
N

N
N
N

N