Form SF 85 P SF 85 P SF 85 P Draft Content Guide

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE

Questionnaire for Public Trust Positions
OMB No. 3206–0258
Form: SF 85P

Interactive/Branching
Electronic Questionnaire

Questionnaire
Content Guide

(DRAFT for 30 Day
Notice)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
General Electronic Form Notes/Notices (all Sections)
The questions/content captured in this document are intended to display what data will be captured from the subject
and the questions to be presented based on the subject’s responses during data capture.
Question numbering and “electronic form navigation notes” have been made throughout this form to help facilitate
review and navigation. These items are subject to change based on the data collection or processing systems this
form may be implemented in. Additionally numbering and electronic form notes are not to be considered part of the
content of the form. Only the section numbers are applicable as the official numbering for this form.
Screens may vary based on html style formatting, java scripting, data capture formatting, system functionality,
validation, and navigation. Systems that are used for the collection of the “Questionnaire for Public Trust Positions
(SF 85P)” data for investigative purposes are subject to OMB review and approval.
Dropdown lists throughout this form (such as listings of countries, document types, etc.) are subject to change based
on changes or requirements of federal information processing standards and other updates/changes to pertinent
information collection, consistent with approved content.

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
OFFICE OF PERSONNEL MANAGEMENT
Questionnaire for Public Trust Positions, SF 85P

Questionnaire for Public Trust Positions
Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.
All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties
for inaccurate or false statements are discussed below. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully
could result in an adverse personnel action against you, including loss of employment; with respect to Sections 21, 25, and 27, however, neither your truthful responses nor information
derived from those responses will be used as evidence against you in a subsequent criminal proceeding.
Note: If you complete the SF 85P, an Authorization for Release of Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) will be provided
to you only in the event information arises in an investigation that requires further inquiry for resolution, and only to resolve such issues. This release authorizes an investigator to ask
your health practitioner(s) only the questions specified on the release concerning mental health consultations of which the practitioner might be aware. If you are completing the
SF 85P with the supplemental SF 85P-S, this release will be provided to you if you respond “yes” to the question regarding Your Medical Record. You may also be asked to complete
a specific release if more detailed information is needed from your provider.
Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, public
trust positions as defined in 5 CFR 731. This form may also be used by agencies in determining whether a subject performing work for, or on behalf of, the Government under a
contract should be deemed eligible for logical or physical access when duties to be performed by an employee of a contractor are equivalent to the duties performed by an employee in a
public trust position. For applicants, this form is to be used only after a conditional offer of employment has been made. This form is not to be used for National Security sensitive
positions.
Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely
affect your eligibility for a public trust position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information
provided be true and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and
duties, and consistency with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for a public trust position, or your
ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your eligibility for physical and logical access
to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect your employment prospects and job status,
and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.
This form is a permanent document that may be used as the basis for future investigations, suitability or fitness for Federal employment, fitness for contract employment, or eligibility
for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your responses to previous SF 85P
questionnaires.
The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and
efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, social security number, and
date and place of birth.
Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders 10450, 13467, 10577, 13467, and 13488;
sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations (CFR), and Federal information processing
standards..
Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay
the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397, as amended by EO 13748.
Your spouse’s SSN is needed solely to allow the investigative service provider to make inquiries regarding whether there is relevant conduct on your part as a result of your relationship
with your spouse. Your spouse is not subject of the investigation.
The Investigative Process
Background investigations for public trust positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and loyal to
the U.S. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation. The investigation may
extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although you may have previously
indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or credit report file, then we may
not be able to complete your investigation, which can adversely affect your eligibility for a public trust position or your ability to obtain Federal or contract employment. To avoid such
delays, you must request that the consumer reporting agencies lift the freeze in these instances.
In addition to the questions on this form, inquiry also is made about your adherence to security requirements your honesty and integrity, falsification, misrepresentation, and any other
behavior, activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal.
After a suitability /fitness determination is made, you may also be subject to continuous vetting which may include periodic reinvestigations to ensure your continuing suitability for
employment.
Your Personal Interview
Some investigations will include an interview with you as a routine part of the investigative process. The investigator may ask you to explain your answers to any question on this form.
This provides you the opportunity to update, clarify, and explain information on your form more completely, which often assists in completing your investigation. It is imperative that
the interview be conducted as soon as possible after you are contacted. Postponements will delay the processing of your investigation, and declining to be interviewed may result in
your investigation being delayed or canceled.
For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to verify your identity, as
instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be
asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention. These matters include (a) alien registration or
naturalization documentation; (b) delinquent loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support, alimony, or
property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court records.
Instructions for Completing this Form
1. Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form.
You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.
2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise
noted.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country dropdown
feature.
4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be provided. For locations outside of the U.S. and its territories, select
the country in the "Country" dropdown list and leave the "State" field blank.
5. Do not abbreviate the names of cities or foreign countries.
6. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.
7. For telephone numbers in the U.S., ensure that the area code is included.
8. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the dropdown lists to select the month and day. The year should be entered as a four character
number (i.e., 1978 or 2001.), or selected from a dropdown list. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate this by
checking the "Est." box.
*****Instructions for Completing this Form (Paper Form Only) *****
1. Follow the instructions, provided to you by the office that gave you this form and any other clarifying instructions provided by that office to assist you with completion of this form.
You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.
2. Type or legibly print your answers in ink. If the form is not legible, it will not be accepted. You may also be asked to submit your form using the approved electronic format.

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
3. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form with "N/A," unless otherwise noted.
4. Any changes that you make to this form, after you sign it, must be initialed and dated by you. Under extremely limited circumstances, agencies may modify your response(s) with
your consent.
5. You must use the Location codes (abbreviations), listed on the back of this page, when you fill out this form. Do not abbreviate the names of cities or foreign countries.
6. Whenever "City (Country)" is indicated in an address block, also provide the name of the country in that same block when the address is outside the U.S.
7. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.
8. For telephone numbers in the U.S., ensure that the area code is included.
9. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use numbers (01-12) to indicate months. For example, July 29, 1968, should be written as
07/29/1968. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate "APPROX." or "EST" in the field.
10. If additional space is required for an explanation or to list your residences, employment/self- employment/unemployment, or education, you should use a continuation sheet, SF
86A.
If additional space is required to answer other items, use a continuation sheet or a blank sheet(s) of paper. Include your name and SSN at the top of each blank sheet (s) used.
Final Determination on Your Suitability
Final determination on your suitability for a public trust position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation.
You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made. The United States Government does not discriminate on the basis of
prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, and sexual orientation, when making
determinations of suitability for a public trust position.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to five (5) years
imprisonment. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent
record for future placements. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any
information you provide on this form and to make your comments part of the record.
Disclosure Information
The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and
disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have
published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information
collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C.
552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. The office that gave you this form will provide you a copy of its routine uses.
Office of Personnel Management (OPM) Routine Uses
The Privacy Act routine uses of agencies conducting or requesting investigations, or with authorized custody over your investigative information, commonly
include some or all of the following:
a. To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government or the Government
of the District of Columbia having a need to investigate, evaluate, or make a determination regarding loyalty to the United States; qualifications, suitability, or fitness for Government
employment or military service; eligibility for logical or physical access to federally-controlled facilities or information systems; eligibility for access to classified information or to
hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.
b. To an element of the U.S. Intelligence Community as identified in E.O. 12333, as amended, for use in intelligence activities for the purpose of protecting United States national
security interests.
c. To any source from which information is requested in the course of an investigation, to the extent necessary to identify the individual, inform the source of the nature and purpose of
the investigation, and to identify the type of information requested.
d. To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or
order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.
e. To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with its current
employee’s, contractor employee’s, or military member’s retention; loyalty; qualifications, suitability, or fitness for employment; eligibility for logical or physical access to federallycontrolled facilities or information systems; eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the
Government under contract, grant, or other agreement; or access to restricted areas.
f. To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from
the subject of the investigation.
f.
g. To disclose information to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government.
h. For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative
support.
i. To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.
j. To appropriate agencies, entities, and persons when (1) OPM suspects or has confirmed that there has been a breach of the system of records; (2) OPM has determined that as a
result of the suspected or confirmed breach there is a risk of harm to individuals, the agency (including its information systems, programs and operations), the Federal Government, or
national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with OPM’s efforts to respond to the suspected or
confirmed breach or to prevent, minimize, or remedy such harm.
k. To another Federal agency or Federal entity, when OPM determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in
(1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the agency (including its information systems, programs
and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.
l. To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, when the
Government is a party to the judicial or administrative proceeding. In those cases where the Government is not a party to the proceeding, records may be disclosed if a subpoena has
been signed by a judge.
m. To disclose information to the National Archives and Records Administration for use in records management inspections.
n. To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which OPM is authorized to appear,
when:
1)
OPM, or any component thereof; or
2)
Any employee of OPM in his or her official capacity; or
3)
Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or
4)
The United States, when OPM determines that litigation is likely to affect OPM or any of its components;
is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OPM is deemed by OPM to be relevant and necessary to the
litigation, provided, however, that the disclosure is compatible with the purpose for which records were collected.
o. For the Merit Systems Protection Board--To disclose information to officials of the Merit Systems Protection Board or the Office of the Special Counsel, when requested in
connection with appeals, special studies of the civil service and other merit systems, review of OPM rules and regulations, investigations of alleged or possible prohibited personnel
practices, and such other functions, e.g., as promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by law.
p. To disclose information to an agency Equal Employment Opportunity (EEO) office or to the Equal Employment Opportunity Commission when requested in connection with
investigations into alleged or possible discrimination practices in the Federal sector, or in the processing of a Federal-sector EEO complaint.
q. To disclose information to the Federal Labor Relations Authority or its General Counsel when requested in connection with investigations of allegations of unfair labor practices or
matters before the Federal Service Impasses Panel.

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
r. To another Federal agency’s Office of Inspector General when OPM becomes aware of an indication of misconduct or fraud during the applicant’s submission of the standard forms.
s. To another Federal agency’s Office of Inspector General in connection with its inspection or audit activity of the investigative or adjudicative processes and procedures of its agency
as authorized by the Inspector General Act of 1978, as amended, exclusive of requests for civil or criminal law enforcement activities.
t. To a Federal agency or state unemployment compensation office upon its request in order to adjudicate a claim for unemployment compensation benefits when the claim for benefits
is made as the result of a qualifications, suitability, fitness, security, identity credential, or access determination.
u. To appropriately cleared individuals in Federal agencies, to determine whether information obtained in the course of processing the background investigation is or should be
classified.
v. To the Office of the Director of National Intelligence for inclusion in its Scattered Castles system in order to facilitate reciprocity of background investigations and security
clearances within the intelligence community or assist agencies in obtaining information required by the Federal Investigative Standards.
w. To the Director of National Intelligence, or assignee, such information as may be requested and relevant to implement the responsibilities of the Security Executive Agent for
personnel security, and pertinent personnel security research and oversight, consistent with law or executive order.
x. To Executive Branch Agency insider threat, counterintelligence, and counterterrorism officials to fulfill their responsibilities under applicable Federal law and policy, including but
not limited to E.O. 12333, 13587 and the National Insider Threat Policy and Minimum Standards.
y. To the appropriate Federal, State, local, tribal, foreign, or other public authority in the event of a natural or manmade disaster. The record will be used to provide leads to assist in
locating missing subjects or assist in determining the health and safety of the subject. The record will also be used to assist in identifying victims and locating any surviving next of kin.
z. To Federal, State, and local government agencies, if necessary, to obtain information from them which will assist OPM in its responsibilities as the authorized Investigation Service
Provider in conducting studies and analyses in support of evaluating and improving the effectiveness and efficiency of the background investigation methodologies.
aa. To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with the classifying
of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the
requesting agency’s decision on the matter.
**LOCATION CODES (PAPER FORM ONLY, Electronic forms to use dropdown lists)**
Alabama AL, Alaska AK, Arizona AZ, Arkansas AR, California CA, Colorado CO, Connecticut CT, Delaware DE, District of Columbia DC, Florida FL, Georgia GA, Hawaii HI,
Idaho ID, Illinois IL, Indiana IN, Iowa IA, Kansas KS, Kentucky KY, Louisiana LA, Maine ME, Maryland MD, Massachusetts MA, Michigan MI, Minnesota MN, Mississippi MS,
Missouri MO, Montana MT, Nebraska NE, Nevada NV, New Hampshire NH, New Jersey NJ, New Mexico NM, New York NY, North Carolina NC, North Dakota ND, Ohio OH,
Oklahoma OK, Oregon OR, Pennsylvania PA, Rhode Island RI, South Carolina SC, South Dakota SD, Tennessee TN, Texas TX, Utah UT, Vermont VT, Virginia VA, Washington
WA, West Virginia WV, Wisconsin WI, Wyoming WY American Samoa AS, Guam GU, Northern Mariana Islands MP, Puerto Rico PR, Virgin Islands of the U.S. VI
Public Burden Information (Electronic)
Public burden reporting for this collection of information is estimated to average 155 minutes per response, 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.
The OMB clearance number, 3206-0258, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
*************PUBLIC BURDEN INFORMATION (PAPER FORM ONLY)**********
Public Burden Information
Public burden reporting for this collection of information is estimated to average 155 minutes per response, 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-XXXX, is currently valid. OPM may not collect
this information, and you are not required to respond, unless this number is displayed.
--------------------END OF INSTRUCTION PAGES -------------------

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the
penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal
YES NO
Service.

Agency Use Block “AUB”
Investigating agency user only
Codes:
(FIPC CODES)
Case Number:
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION
PROVIDED IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE,
THOSE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
A – Type of Investigation
B – Extra coverage / advanced results
C – Risk level
E – Nature of action code
F – Date of action
G – Geographic location
H – Position code
I – Position title
J – SON (Submitting Office Number )
K – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other
Other address / web address of e-OPF
Zip Code
L – SOI (Security Office Identifier)
M – Location of Security Folder _ None _ NPI _ At SOI _e-OPF _ Other
Other address
Zip Code
N – IPAC
O – TAS
P – Obligating document number
Q - BETC
R – Accounting data and /or Agency case number
S – Investigative requirement _Initial _Reinvestigation
T – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date
U – Secondary Requesting Official: Name, Title, Email Address, Telephone Number
V – Applicant Affiliation _ FED CIV _ CON _ MIL _ Other
W – Deployment/PCS (if Imminent): (Paper form not formatted just open block, Electronic Formatted collecting the below information)
From-To Dates, Estimated, Permanent Relocation Reason(s) for temporary duty assignment, or PCS, point of contact at location, Telephone (Include
Ext) address/unit/duty location (Include City or Post Name)
Agency Special Instructions for the Investigative Service Provider: e-QIP Only – Used in place of a hardcopy cover memoCage Code
Contracting Number

Beginning of Questionnaire

FOR REFERENCE ONLY, NOT A FORM FOR COMPLETION
Section 1 – Full Name
Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you
do not have a middle name, indicate “No Middle Name”. If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last

First

Middle

Suffix

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Section 2 – Date of Birth
Provide your date of birth.

Date (Estimated)

Section 3 – Place of Birth
Provide your Place of birth.

City

County

State

Country

Section 4 – SSN
Provide your U.S. Social Security Number.

□ Not applicable _ _ _-_ _-_ _ _ _

Section 5 – Other Names Used
Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by a former marriage (s), former
name(s), alias (es), or nickname(s)).
Have you used any other names?
YES
NO
Provide your other name used and the period of time you used it [for example: your maiden name, name by a former marriage,
Branch
former name, alias, or nickname]. If you have only initials in your name, provide them and indicate “Initial only.” If you do not
If Yes to
have a middle name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
“Other
Provide other name used.
Last
First
Middle
Suffix
Maiden name?
Yes
No
Names”
Provide dates used.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple
Provide the reason(s) why the name changed.
Reason: (Free Text)
Entries
Summary of other names used:
Allowed)
Do you have additional names to enter?
Yes (Yes adds another entry)
No (Required to pass validation)

Section 6 – Your Identifying Information
Provide your Identifying Information

Height

(feet)

(inches)

Weight (in pounds)

Hair Color

Eye Color

Sex (M/F)

Section 7 – Your Contact Information
Provide three contact numbers. At
least one telephone number is
required. Additional numbers
provided may assist in completion of
your background investigation. your
contact information
Home telephone number
Extension Time: Day/Night Both
Check box if International DSN

Home email address

Email (Free Text)

Work telephone number
Extension Time: Day/Night Both
Check box if International DSN

Work email address

Email (Free Text)

Mobile/Cell telephone number
Extension Time: Day/Night Both
Check box if International DSN

Section 8 – U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
Provide the following information for the most recent U.S. passport you currently possess:
Branch
Provide your passport number
Passport (Free Text)
Click HERE for U.S. State Department passport help. http://travel.state.gov/passport
If Yes to
Provide the issue date of passport.
Date (Estimated)
Provide the expiration date of passport.
“passport”
Provide the name in which passport was first issued.
Last
First
Middle

YES

NO

Date (Estimated)
Suffix

Section 9 – Citizenship
Select the box that reflects your current citizenship status and click Save.
Provide your current citizenship status:
□ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. □ I am a naturalized U.S. citizen. □I am a derived U.S.
citizen.□ I am not a U.S. citizen.
You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide type of documentation of U.S. citizen born abroad.
Explanation
(FS) 240, DS 1350 FS545, Other (Provide explanation)
Provide document number for U.S. citizen born abroad:
Document Number (Free Text)
Branch
Provide the date the document was issued.
Date (Estimated)
Provide the place of issuance.
City
State
Country
Foreign Born
Last
First
Middle
Suffix
to U.S. Parents Provide the name in which document was issued.
in a Foreign
Provide your citizenship certificate number.
Certificate Number (Free Text)
Country
Provide the place of issuance.
City
State
Court
Provide the date the certificate was issued.
Date (Estimated)
Provide the name in which the certificate was issued.
Last
First
Middle
Suffix
Were you born on a U.S. military installation?
YES NO
You answered that you were born on a U.S. military installation.
Branch If Yes
Provide the name of the base.
Name (Free Text)
You answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S.
Date (Estimated)
Provide the location of entry into the U.S.
City
State
Provide country(ies) of prior citizenship.
Country (Allows for Multiples)
Do/did you have a U.S. alien registration number?
YES NO
Branch
Branch If Yes
Provide your U.S. alien registration number on
Alien Registration Number (Free Text)
Certificate of Naturalization – utilize USCIS,
Citizenship
CIS, or INS registration number, I-EE1, I-766.
Naturalized
Provide your citizenship certificate number.
Citizenship Certificate Number (Free Text)
U.S. Citizen
Provide the location of the court where the citizenship certificate was issued.
Court (Free Text)
Street
City
State
Zip
Provide the date the citizenship certificate was issued.
Date (Estimated)
Provide the name in which the citizenship certificate was issued.
Last
First
Middle
Suffix
Provide your naturalization Certificate Naturalization number (N550 or
Naturalization Certificate of Naturalization

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE

Branch
Citizenship
Derived

Branch
Citizenship
Not a U.S.
citizen

N570).
Number (Free Text)
Provide the name of location of the court that issued the Certificate of
Court (Free Text)
Naturalization certificate. where naturalization certificate was issued.
Provide the address of the court
that issued the Certificate of
Naturalization.
Street
City
State
Zip
Provide the date the Certificate of Naturalization naturalization certificate
Date (Estimated)
was issued.
Provide the name in which the Certificate of Naturalization naturalization
Last
First
Middle
Suffix
certificate was issued.
Provide the basis of naturalization. - Based on my own individual naturalization application,
Explanation
- By operation of law through my U.S. citizen parent. - Other (Provide explanation)
You answered that you are a derived U.S citizen
Provide your alien registration number (on Certificate of
Alien Registration number. (Free Text)
Citizenship—utilize USCIS, CIS or INS registration number).
Provide your Permanent Resident Card number (I-551)
Permanent Resident Card number (I-551) (Free Text)
Provide your Certificate of Citizenship number (N560 or N561)
Certificate of Citizenship number (N560 or N561) (Free
Text)
Provide the name in which the document was issued.
Last name:
First
Middle name:
name:
Suffix:
Provide the date document was issued
Estimate
Provide the basis of derived citizenship –By operational of law
through my U.S citizen parent. Other (provide explanation)
Not a U.S. Citizen
Provide your residence status.
Status (Free Text)
Provide the date of entry into the U.S.
Date (Estimated)
Provide your country (ies) of citizenship. (allow multiple
Provide your place of entry in the U.S. City (Free Text) State
entries)
Provide your alien registration number.(I-151, I766)
Registration Number (Free Text)
Provide document expiration date (I766 ONLY)
Provide type of document issued. (I-94, U.S Visa – red
I-94, U.S. Visa( red foil number), I-20, DS-2019,
Explanation
foil number, I-20 DS-2019, etc.)
Other (Provide explanation)
Provide document number:
Document Number (Free Text)
Provide the name in which the document was issued.
Last
First
Middle
Suffix
Provide the date document was issued.
Date (Estimated)
Provide the document expiration
Date (Estimated)
date of visa.

Section 10 – Dual/Multiple Citizenship & Foreign Passport Information
Do you now or have you EVER held dual/multiple citizenships?
YES NO
You answered “Yes” to having EVER held dual/multiple citizenship
Provide country of citizenship
During what period of time did you hold citizenship with this country?
Branch
Provide the date range that you held this citizenship; beginning with the date it was
From Date
To Date
acquired through its termination or “Present,” whichever is appropriate.
(Estimated)
(Estimated/Present)
Dual/Multiple
How did you acquire this non-U.S. citizenship you now have or previously had?
How (Free Text)
Citizenship
(Multiple
Entries
Allowed)

Do you currently hold citizenship with this country?
YES NO
Branch
If Present/Current
Provide explanation:
Summary of dual/multiple citizenships you have listed:
Do you have an additional citizenship to provide?
YES (Yes adds another entry)
NO (Required to validate)
Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?
YES NO
You responded “Yes” to having been issued a passport (or identity card for travel) by a country other than the U.S.
Provide the country in which the passport (or identity card) was issued.
Country:
Provide the date the passport (or identity card) was issued.
Date (Estimated)
Branch
Provide the place the passport (or identity card) was issued.
City
Country
Provide the name in which passport (or identity card) was issued:
Last
First
Middle
Suffix
Foreign
Passport (or
Provide the passport (or identity card) number.
Passport# (Free Text)
Identity Card)
Provide the passport (or identity card) expiration date.
Date (Estimated)
Have you EVER used this passport (or identity card) for foreign travel?
YES NO
(Multiple
Provide the countries to which you traveled on this
Country
From Date
To Date
Branch
Entries
(Multiple Entries Allowed)
passport (or identity card) and the dates involved with
(Estimated)
(Est/Pres)
Allowed)
each
Do you have an additional foreign passport (or identity card) to
YES
NO
report?
(Yes adds another entry)
(Required to validate)

Section 11 – Where You Have Lived
List the places where you have lived beginning with your present residence and working back 7 years. Residences for the entire period must be
accounted for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you
were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list
residence before your 18th birthday unless to provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who
knew you well for periods of residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
for residence.
Enter residence information. (Multiple Entries Allowed)
Provide dates of residence.
From Date (Estimated)
To Date (Estimated/Present)
Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation)
Explanation (Free Text)
Provide the street address.
Street address and City
State and Zip Code or Country
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country
Branch
Physical
location or home port/fleet headquarter. Provide physical location data:
Location
Street Address/Unit/Duty Location:
City or Post Name
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the U.S.
Branch
APO/FPO
Do/did you have an APO/FPO address while at this location
Yes
No
Address
Branch If Yes
Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code Zip Code
Provide the name of a neighbor, landlord (if rental) or other person who knows you at this address.
Provide the full name:
Last
First
Middle
Suffix
Provide date of last contact:
Date (Estimated)
Provide your relationship to this person (check all that apply)
□ Neighbor □ Friend □ Landlord □ Business associate
□ Other (Provide explanation) Explanation (Free Text)
Provide the following contact information for this person :
Provide evening phone number for this person: Number/Ext
Provide daytime phone number for this person: Number/Ext
_ Check box
Check box if
Branch
if
international
international
Person Who
__I don’t
_I don’t
Knew you
know
know
Provide cell/mobile phone number for this person:
Number/Ext _Check box if international _ I don’t know
(if address
Provide e-mail address for this person:
Email (Free Text)
dates within
Provide street address for this person (including apt number).
Street address and City
State and Zip Code or Country
last 3 years)
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name
Location
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the U.S.
Branch
APO/FPO
Does the person who knew you have an APO/FPO address?
Yes
No
Address
Branch If Yes Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code
Zip Code
Do you have an additional residence to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 12 – Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed)
Have you attended any schools in the last 7 years?
YES NO
Have you received a degree or diploma more than 7 years ago?
YES NO
Provide the dates of attendance.
From Date (Estimated)
To Date (Estimated/Present)
Select the most appropriate box to describe your school. □ High School □ College/University/Military College
□ Vocational/Technical/Trade School
□ Correspondence/Distance/Extension/Online School
Provide the name of the school:
Name (Free Text)
Provide the street address of the school. For correspondence/distance/
Street address and City
extension/online schools, provide the address where the records are maintained.
State and Zip Code or Country
For assistance determining the school address, refer to
http://ope.ed.gov/accreditation/search.aspx
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not
list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online
schools, list someone who knew you while you received this education.
Branch
Provide the name of person who knows/knew you at school: □ I don’t know
Name
Branch
(Free Text)
If Yes to
Provide current address for this person (including apartment number).
If Yes to
Attending
Street address and City
State and Zip Code or Country
Receiving
Schools
Degree
Provide telephone number for this person.
Number/Ext Check box if
international
_I don’t know
Provide email address for this person: □ I don’t know
Email (Free Text)
Did you receive a degree/diploma?
YES NO
Provide type of degrees(s)/diploma(s) received and date(s) awarded:
Branch
Degree/diploma
• High School Diploma
Other degree/diploma
If Yes to
• Associate’s • Bachelor’s • Master’s • Doctorate
Other Degree (Free Text)
Receiving Degree
• Professional Degree (e.g. MD, DVM, JD) • Other
Month / Year
Date (Estimated)
Do you have additional education to enter (include education within the last 7
YES (Yes adds
NO (Required
years, as well as degrees or diplomas more than 7 years ago)?
another entry)
to validate)

Section 13a – Employment Activities – Employment & Unemployment Record
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The
entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show
each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical address.
Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.
(Multiple Entries Allowed)
Select your employment activity: □ Active military duty station □ National Guard/Reserve □ USPHS Commissioned Corps
□ Other Federal employment
□ State Government (Non-Federal employment)
□ Self-employment □ Unemployment

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
□ Federal Contractor
□ Non-government employment (excluding self-employment)
□ Other (Provide explanation)
Other Type Explanation (Free Text)
Provide dates of employment.
From Date (Estimated)
To Date (Estimated/Present)
Active Duty, National Guard/Reserve, or USPHS Commissioned Corps
Select the employment status for this position: □ Full-time □ Part-time
Provide your assigned duty
Duty station (Free Text)
Provide your most recent
Rank/position (Free Text)
station during this period.
rank/position title.
Provide address of duty station.
Street address and City
State and Zip Code or Country
Telephone number
Number/Ext.
Time Day Night Both _ Check box if international or DSN phone
number
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on
more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3
separate periods of time, you would enter information concerning the most recent period of employment above, and provide
dates, position titles, and supervisors for the two previous periods of employment as entries below). Not Applicable □
(Multiple Entries Allowed)
Dates of employment
From Date (Estimated)
To Date (Estimated/Present)
Branch
Position title
Position (Free Text)
Supervisor
Supervisor (Free Text)
You have indicated an APO/FPO address; provide physical location data with either street address, base, post,
Branch
If Employment
embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Type is Active
Street Address/Unit/Duty Location:
City or Post Name:
Location
Duty, National
Provide state for ports in the United States, or country location.
State and Zip Code or Country
Guard/Reserve,
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
or USPHS
address while at this location?
APO/FPO
Commissioned
Address
Branch If Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Corps
Provide the name of your supervisor.
Supervisor name (Free Text)
Provide the rank/position title of your supervisor.
Supervisor rank/position (Free Text)
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Provide the physical work location of your supervisor.
Street address and City
State and Zip Code or Country
Provide supervisor telephone number
Number/Ext. Time Day Night Both _ Check box if
international or DSN phone number
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street
address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
Branch
data of your supervisor:
Physical
Location
Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other
Provide most recent position title.
Position (Free Text)
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employer
Employer name (Free Text)
Provide the address of employer
Street address and City
State and Zip Code or Country
Provide telephone number
Number/Ext. Time Day Night
Both _ Check box if
international or DSN phone
number
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on
more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3
separate periods of time, you would enter information concerning the most recent period of employment above, and provide
Branch
dates, position titles, and supervisors for the two previous periods of employment as entries below). Not Applicable □
(Multiple Entries Allowed)
If Employment
Dates of employment
From Date (Estimated)
To Date (Estimated/Present)
Type is Other
Position title
Position (Free Text)
Supervisor
Supervisor (Free Text)
Federal
Is/was your physical work address different than your employer’s address?
YES NO
employment,
Provide the work address where you are/were physically located.
Branch
State
Street address and City
State and Zip Code or Country
Physical
Government,
Provide telephone number:
Number/Ext. Time Day Night Both _ Check box if
Location
Federal
international or DSN phone number
Contractor, NonYou have indicated an APO/FPO address; provide physical location data with either street address, base, post,
government
Branch
embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:
employment, or
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Other
Location
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Provide the name of your supervisor.
Supervisor name (Free Text)
Provide the position title of your supervisor.
Supervisor position (Free Text)
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Provide the physical work location of your supervisor.
Street address and City
State and Zip Code or Country
Provide supervisor telephone number
Number/Ext.
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street
Branch
Physical
address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
Location
data of your supervisor:

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE

Branch
If Employment
Type is SelfEmployment

Branch
If Employment
Type is
Unemployment

Branch
If Employment
Type is Active
Duty, National
Guard/Reserve,
USPHS
Commissioned
Corps, Other
Federal
employment,
State
Government,
Federal
Contractor, Nongovernment
employment,
SelfEmployment,
Unemployment,

Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Self-Employment
Provide most recent position title.
Position (Free Text)
Select the employment status for this position:
□ Full-time □ Part-time
Provide the name of your employment
Employment name (Free Text)
Provide the address of employer
Street address and City
State and Zip Code or Country
Provide telephone number
Number/Ext. Time Day Night
Both _ Check box if
international or DSN phone
number
Is your physical work address different than your employment address?
YES NO
Provide the work address where you are/were physically located.
Street address and City
State and Zip Code or Country
Branch
Provide telephone number:
Number/Ext. Time Day Night
Physical
Both _ Check box if
Location
international or DSN phone
number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post,
Branch
embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Provide the name of someone that can verify your self-employment.
Last
First
Provide the address of this verifier.
Street address and City
State and Zip Code or Country
Provide the telephone number for this person
Number/Ext. Time Day Night Both _ Check box if
international or DSN phone number
You have indicated an APO/FPO address for your self employment verifier; provide physical location data with
Branch
either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide
Verifier
physical location data for this person
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Does your self employment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Unemployment
Provide the name of someone who can verify your unemployment activities and means of support
Last
First
Provide the address of this verifier.
Street address and City
State and Zip Code or Country
Provide the telephone number for this person
Number/Ext.
You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with
Branch
either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide
Verifier
physical location data for this person:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Does your unemployment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Provide the reason for leaving the employment activity.
Reason (Free Text)
For this employment have any of the following happened to you in the last seven (7) years?
YES NO
• Fired • Quit after being told you would be fired • Left by mutual agreement following charges or
allegations of misconduct • Left by mutual agreement following notice of unsatisfactory performance

Branch
If Fired, Quit,
Left by Mutual
Agreement, or
Left After
Unsatisfactory
Performance
(Multiple
Entries
Allowed)

Select the type of incident: • Fired • Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
• Left by mutual agreement following notice of unsatisfactory performance
Provide the reason for being fired.
Reason (Free Text)
Branch
If Fired
Provide the date you were fired.
Date (Estimated)
Provide the reason for quitting.
Reason (Free Text)
Branch
Provide the date you quit after being told you would be
Date (Estimated)
If Quit
fired.
Provide the charges or allegations of misconduct.
Charges (Free Text)
Branch
Provide the date you left following charges or allegations
Date (Estimated)
If Left after Charges
of misconduct.
Provide the reason(s) for unsatisfactory performance.
Reason (Free Text)
Branch
If Left Unsatisfactory Provide the date you left by mutual agreement following a Date (Estimated)
performance
notice of unsatisfactory performance.
In the last seven (7) years do you have another reason for leaving to
YES (Yes adds
NO (Required

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
or Other

report for this employment?
another entry)
to validate)
For this employment, in the last seven (7) years have you received a written warning, been officially
YES NO
reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?
Officially reprimanded, suspended, or disciplined for misconduct.
Branch
If Disciplined,
Provide the month and year you were warned, reprimanded, suspended or
Date (Estimated)
Warned,
disciplined.
Reprimanded, or
Provide the reason(s) for being warned, reprimanded, suspended or disciplined
Reason (Free Text)
Suspended
Do you have another instance of discipline or a warning to
YES (Yes adds
NO (Required
(Multiple Entries
provide?
another entry)
to validate)
Allowed)
Do you have an additional employment activity to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 13b – Employment Activities – Former Federal Service
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
YES NO
Former Federal Service Detail
Branch
Provide dates of federal civilian employment.
From Date (Estimated)
To Date (Est/Present)
Provide the name of the federal agency for which you are/were employed.
Name
If Yes to Former
Federal Service
Provide your position title.
Position title (Free Text)
Provide the location of the agency
Street address and City
State and Zip Code or Country
(Multiple Entries
Do you have additional former federal civilian employment, excluding military
YES (Yes adds
NO (Required
Allowed)
service, NOT indicated previously, to report?
another entry)
to validate)

Section 13c – Employment Record
Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed? (If Yes, you will
be required to add an additional employment in Section 13a)
• Fired from a job?
• Quit a job after being told you would be fired?
• Have you left a job by mutual agreement following charges or allegations of misconduct?
• Left a job by mutual agreement following notice of unsatisfactory performance?
• Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as violation of a security
policy?
YES NO

Section 14 – Selective Service Record
Were you born a male after December 31, 1959?
YES
NO
Selective Service Registration
Have you registered with the Selective Service System (SSS)
I don’t know
YES
NO
The Selective Service website, www.sss.gov, can help provide the registration number for persons who have
Branch
Branch
registered. Note: Selective Service Number is not your Social Security Number
If Yes
Provide registration number:
Registration number (Free Text)
If Yes to Born
You responded 'No' to having registered with the Selective Service System (SSS)
Branch
Male After
If No
Provide explanation
Explanation (Free Text)
12/31/1959
You responded 'I don't know' to having registered with the Selective Service System (SSS)
Branch
If I Don’t Know
Provide explanation
Explanation (Free Text)

Section 15 – Military History
Have you EVER served in the U.S. Military?
YES NO
You responded ‘Yes’ to having served in the U.S. Military:
Provide the branch of service you served in:
State if National Guard
Officer or enlisted: Provide your service
□ Army □ Army National Guard
□ Not Applicable
number.
Provide your status
□ Navy □ Air Force □ Air National Guard
□ Officer
□ Active Duty □ Active Reserve
Number (Free Text)
□ Marine Corps □ Coast Guard
□ Enlisted
□ Inactive Reserve
Provide your dates of service
From Date (Estimated)
To Date (Estimated/Present)
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES NO
You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves
or National Guard; answer the following:
Branch
Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable
Conditions □ General □ Bad Conduct □ Other (provide type)
If Yes to
Branch
Discharged
Provide other discharge type:
Discharge explanation (Free Text)
Provide the date of discharge listed above
Date (Estimated
If Yes to
Branch If Discharge Not Honorable
Provide the reason(s) for the discharge.
Reason(s) (Free Text)
Serving in
the U.S.
In the last 7 years, have you been subject to court martial or other disciplinary procedure under the Uniform Code of
YES NO
Military
Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc?
You responded ‘Yes’ to having been subject to court martial or other disciplinary procedure under the Uniform Code
(Multiple
of Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc in the last 7 years.
Entries
Provide the date of the court martial or other disciplinary procedure.
Date (Estimated)
Allowed)
Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you
Description
were charged.
(Free Text)
Branch
Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast,
Name
If Yes to
Article 135 Court of Inquiry, etc.
(Free Text)
Military
Provide the description of the military court or other authority in which you were charged (title of
Description
Discipline
court or convening authority, address, to include city and state or country if overseas).
(Free Text)
Provide the description of the final outcome of the disciplinary procedure, such as found guilty,
Description
found not guilty, fine, reduction in rank, imprisonment, etc.
(Free Text)
In the last 7 years do you have an additional
YES (Yes adds another entry)
NO (Required to validate)
instance of military discipline to report?
Do you have additional military service to report?
YES (Yes adds another entry)
NO (Required to validate)
Have you EVER served, as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces,
YES NO

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
militia, other defense force, or government agency?
You responded ‘Yes’ to having EVER served as a civilian or military member in a foreign country’s military, intelligence,
diplomatic, security forces, militia, other defense force, or government agency.
Branch
During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc), Specify
□ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government
If Yes to
Serving in a Agency, Specify
Provide the name of the foreign organization.
Name (Free Text)
Foreign
Provide your period of service
From Date (Estimated)
To Date (Estimated/Present)
Military
Provide the name of the country
Provide your highest position/rank held
Position held (Free Text)
(Multiple
Provide the division/department/office in which you served.
Division (Free Text)
Entries
Provide a description of the circumstances of your association with this organization.
Description (Free Text)
Allowed)
Provide a description of the reason for leaving this service.
Description (Free Text)
Do you have an additional foreign military service to report? Yes (Yes adds another entry) No
(required to validate)

Section 16 – People Who Know You Well
Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates,
associates, etc., who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association
with you covers at least the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.
(Multiple Entries Allowed)
Provide dates known
From Date (Est.)
To Date (Est./Present)
Provide full name
Last
First
Middle
Suffix
Provide rank/title
Rank/title (Free Text) Provide relationship to you: (Check all that apply) □ Neighbor □ Friend
Explanation
□ Not applicable
□ Work associate □ Schoolmate □ Other (Provide explanation)
(Free Text)
Provide phone number for this person.
□ I don’t know
Telephone/Ext.
Provide mobile/cell phone number for this person. □ I don’t know
Telephone/Ext.
Provide e-mail address for this person.
□ I don’t know
Email (Free Text)
Provide home or work address for this person.
Street address and City
State and Zip Code or Country
Do you have an additional person who knows you well to list?
YES (Yes adds another entry)
NO (Required to validate)

Section 17 – Marital/Relationship Status
Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic
partnership: □ Never entered into a civil marriage, legally recognized civil union, or legally recognized domestic partnership □ Currently in a civil
marriage □Currently in a legally recognized domestic partnership or legally recognized civil union □ Separated □ Annulled □ Divorced/Dissolved
□ Widowed
You selected “Currently in a civil marriage,” “currently in a legally recognized civil union or legally recognized domestic
partnership” or “Separated.” Complete the following about the person with whom you are in a civil marriage, legally recognized civil
union, or legally recognized domestic partnership, or the person from whom you are currently separated.
Provide full name
Last
First
Middle
Suffix
Provide date of birth.
Date (Est.)
Provide place of birth
City
County
State or Country
If the person is foreign born, provide one type of documentation that he or she possesses and the document number.
Branch
□ FS 240 or 545
□ DS 1350 □ U.S. Certificate of Citizenship certificate □ U.S. Passport (current or most
If the person
recent)
□ Alien registration □ U.S. Certificate of Naturalization certificate □ None (Provide explanation) □
is Foreign
Other (Provide explanation)
Born
Explanation (Free Text)
Provide document number
Number (Free Text)
Provide
U.S.
Social
Security
Number.
□
Not
applicable
_
_
_-_
_-_
_
_
_
Branch
Provide other names used by your spouse (such as maiden names, names by other
Last
First
Middle
marriages, civil marriages, legally recognized civil unions, or legally recognized
Suffix
□ Maiden Name
If In A
domestic partnerships, nicknames, etc. and provide dates used for each name). □
Marriage,
Not applicable
Civil
Dates Used
From Date (Estimated)
To Date (Estimated/Present)
Union, or
Provide country(ies) of Citizenship
Provide date when you
Date (Estimated)
Domestic
entered into your civil
Partnership
marriage, civil union, or
or
domestic partnership
Separated
Provide location
City
County
State or Country
Provide current address, if different than your current address.
Street address and City
□ Use my current address.
State and Zip Code or Country
Provide telephone number. □ Use my current telephone number
Number/Ext
Provide email address
Email (Free Text)
Does the person have an APO/FPO address?
YES NO
Branch APO/FPO
Address
APO/FPO
APO State Code
Zip
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter.
Physical
Provide physical location
Street Address/unit/duty location City/Post Name
State Zip
Country
Location
data:
Are you separated?
YES NO
Provide date of separation.
Date (Estimated)
Branch
If legally separated, provide the location of the record. □ Not Applicable
If Separated
City
State and Zip Code or Country
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?
YES NO
Provide information about any person from whom you are divorced/dissolved, annulled, or widowed
Provide the full name.
Last
First
Middle
Suffix
Provide the date of birth.
Date (Estimated
Branch
Provide the place of birth.
City
State
Country
If
Provide the country(ies) of citizenship.
Country
Widowed,
Provide the date .
Date (Estimated)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Divorced/
Dissolved,
or Annulled
(Multiple
Entries
Allowed)

Provide the location.

City

State or Country

Provide the date divorced/dissolved, annulled or
Date (Estimated)
widowed
Provide the status
□ Divorced/Dissolved □ Widowed □ Annulled
Pprovide where the record of divorce/dissolution or annulment is located.
City
State and Zip Code or
Country
Branch
Is this person deceased?
I don’t know
YES NO
If Divorced
or Annulled
Pprovide last known address of the person from whom you Street and City
Branch If Not
are divorced/dissolved or annulled.
□ I don’t know
Deceased
State and Zip Code or Country
Do you have any additional person(s) from whom you are
YES
NO
divorced/dissolved, annulled, or widowed to report?
(Yes adds another entry)
(Required to validate)

Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic partner, with whom you share
YES NO
bonds of affection, obligation, or other commitment, as opposed to a person with whom you live for reasons of convenience (e.g. a
roommate) ? If so, complete the following. If the person was born outside the U.S., provide citizenship information.
You have indicated that you currently have a cohabitant
Provide the cohabitant full name.
Last
First
Middle
Suffix
Provide the cohabitant date of birth. Date (Estimated)
Provide the cohabitant place of birth.
City
State
Country
Branch
For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document
number. □ FS 240 or 545 □ DS 1350 □ U.S. Certificate of Citizenship certificate - □ U.S. Passport (current or most
Branch If
If Yes to
recent)
Cohabitant
Residing
□ Alien registration □ U.S. Certificate of Naturalization certificate-□ None (Provide explanation) □ Other (Provide
is Foreign
With a
explanation)
Born
Cohabitant
Explanation (Free Text)
Provide document number
Number (Free Text)
Provide your cohabitant’s U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _
(Multiple
Provide other names used by your cohabitant (such as maiden names, names by
Last
First
Middle
Entries
other marriage, etc., and provide dates each name was used) □ Not applicable
Suffix
□ Maiden Name
Allowed)
Dates Used
From Date (Estimated)
To Date (Estimated/Present)
Provide your cohabitant’s country(ies) of Citizenship
Provide date cohabitation began.
Date (Estimated)
Do you have an additional cohabitant to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 18 – Relatives
Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for
each type.) Check all that apply. □ Mother □ Father □ Stepmother □ Stepfather □ Foster parent □ Child (including adopted/foster) □ Stepchild
Provide relative type. (Multiple Entries Allowed)
□ □ Mother □ Father □ Stepmother □ Stepfather □ Foster parent □ Child (including adopted/foster) □ Stepchild □ Brother □ Sister □
Stepbrother □ Stepsister □ Half-brother □ Half-sister □ Father-in-law □ Mother-in-law □ Guardian
Provide your relative’s full name.
Last
First
Middle
Suffix
Provide your relative’s date of birth.
Date (estimated)
Provide your relative’s place of birth
City
State
Country
Provide your relatives country(ies) of citizenship
Branch - If Mother
Provide your mother’s maiden name. (□ same as listed)
Last
First
Middle
Suffix
Has this relative used any other names?
YES NO
Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage,
Branch
former name, alias, or nickname).
If Other Names
Last
First
Middle
Suffix
Maiden name?
YES NO
From Date (Estimated)
To Date (Estimated/Present)
Provide the reason(s) why the name
Reason
(Multiple Entries
changed
(Free Text)
Allowed)
Has this relative used any additional names?
YES (Yes adds another entry)
NO (Required to validate)
Is your relative deceased?
YES NO
Provide your relative’s current address.
Street address and City
State and Zip Code or Country
Branch
Does this relative have an APO/FPO address?
I don’t know
YES NO
If not Deceased
Branch If APO/FPO Provide your relative’s APO/FPO address
Address
APO/FPO
APO/FPO State
Zip
Do you have an additional relative to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 19 – Foreign Countries You have Visited
Have you traveled outside the U.S. in the last seven (7) years?
YES NO
Has your travel in the last seven (7) years been solely for U.S. Government business on official government orders (i.e., no personal YES NO
trips in conjunction with the official U.S. Government business)?
You response indicates you have traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business.
Provide information about all such trips made outside the United States including personal trips made in conjunction with official
U.S. Government business on official government orders.
Provide the country visited
Provide the dates of your travel to this country. From Date (Estimated)
To Date (Estimated)
Provide the total number of days involved in the visit. □ 1-5 □ 6-10 □ 11-20 □ 21-30 □ More than 30 □ Many short trips
Provide the purpose of the travel to this country (Check all that apply)
□ Business/professional
□ Volunteer activities
□ Education □ Tourism □ Trade shows, conferences, and seminars □ Visit family or friends
□ Other
Branch
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other
Explanation
YES NO
If Having
than for normal customs requirements) by the local customs or security service officials when
(Free Text)
Traveled
entering or leaving this country? If yes provide explanation.
Outside the
While traveling to or in this country, were you involved in any encounter with the police? If yes
Explanation
YES NO
U.S. on
provide explanation.
(Free Text)
Other than
While traveling to or in this country, were you contacted by, or in contact with any person known or
Explanation
YES NO
Official
suspected of being involved or associated with foreign intelligence, terrorist, security, or military
(Free Text)
Business
organizations? If yes provide explanation.
Do you have additional travel outside the U.S. in the last seven (7) years for
YES
NO
(Multiple
other than solely U.S. Government business on official government orders?
(Yes adds another entry) (Required to validate)
Entries
Allowed)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Section 20 – Police Record
For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court
record, or the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an
expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.
Have any of the following happened? (If yes, you will be asked to provide details for each offense that pertains to the actions that are identified
below.)
• In the past last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do
not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs.)
• In the past last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
• In the past last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
• In the past last seven (7) years have you been or are you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
YES NO
Provide the date of offense.

Date (Estimated)

Provide a description of the
Description (Free Text)
specific nature of the offense.
Did this offense involve any of the following? (Check all that apply)
□ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, or legally
recognized civil union /domestic partner former spouse or legally recognized civil union/domestic partner, or someone with whom
you share a child in common?
□ Involve firearms or explosives?
□ Involve alcohol or drugs?
YES NO
Provide the location where the offense occurred.
Street address and city
State and Zip Code or Country
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police
YES NO
officer, sheriff, marshal or any other type of law enforcement official?
Arresting/citing/summoning agency
Branch
If Yes to Being
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Name (free Text)
Arrested/Cited/
Provide the location of the law
Street address and city
State and Zip Code or Country
Summoned
enforcement agency.
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court
YES NO
in a criminal proceeding against you?
Branch - If No
You responded ‘No’ to “As a result of this offense were you charged, convicted, currently awaiting trial, and/or
to Charged or
ordered to appear in court in a criminal proceeding against you?”
Convicted
Provide Explanation
Explanation (Free Text)
Court information
Branch
Provide the name of the court.
Name of court (Free Text)
Provide the location of the court.
Street address and city
State and Zip Code or Country
If Yes to the
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as
Above
found guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded
Happening
guilty to a lesser offense, list separately both the original charge and the lesser offense.
Felony/Misdemeanor
Felony, Misdemeanor, Other
Charge
Charge (Free Text)
(Multiple
Outcome
Outcome (Free Text)
Date (Month/Year)
Date
Entries
Were you sentenced as a result of this offense?
YES NO
Branch
Allowed)
Conviction detail
Provide a description of the sentence.
If Yes to
Charged or
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Branch
Convicted
Were you incarcerated as a result of that sentence for not less than 1 year?
YES NO
If Yes to
Being
If the conviction resulted in imprisonment, provide the dates
From Date (Estimated)
Sentenced
that you actually were incarcerated. (Not Applicable □ )
To Date (Estimated/Present)
If conviction resulted in probation or parole, provide the
From Date (Estimated)
dates of probation or parole. (Not Applicable □ )
To Date (Estimated/Present)
Trial detail
Branch
If No to
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal
YES NO
Being
charges for this offense?
Sentenced
Provide Explanation
Explanation (Free Text)
Do you have any other offenses where any of the following has happened to you?
YES
NO
• In the past last seven (7) years have you been issued a summons, citation, or ticket to
(Yes adds
(Required to
appear in court in a criminal proceeding against you? (Do not include citations involving
another entry)
validate)
traffic infractions where the fine was less than $300 $150 and did not include alcohol or drugs)
• In the past last seven (7) years have you been arrested by any police officer, sheriff,
marshal or any other type of law enforcement official?
• In the past last seven (7) years have you been charged with, convicted of, or sentenced for
of a crime in any court? (Include all qualifying charges, convictions, or sentences in a
Federal, state, local, military, or non-U.S. court even if previously listed on this form.)
• In the past last seven (7) years have you been or are you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
Other than those offenses already listed, have you EVER had the following happen to you?
• Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such as battery or assault) against your child,
dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or
someone with whom you share a child in common?
YES

NO

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Provide the date of the offense.
Date (Estimated)
Provide a description of the specific nature of the offense.
Description of nature of offense (Free Text)
Did this offense involve any of the following?
□ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally
recognized civil union/domestic partner, former spouse or legally recognized civil union domestic/partner , or someone with whom
you share a child in common?

Branch
If Yes to the
Above
Happening
(Multiple
Entries
Allowed)

YES NO
Provide the name of the court.
Name of court (Free Text)
Provide the location of the court.
Street address and city
State and Zip Code or Country
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found
not-guilty, or charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the
original charge and the lesser offense separately.
Felony/Misdemeanor
Felony, Misdemeanor, Other
Charge
Charge (Free Text)
Outcome
Outcome (Free Text)
Date Month/Year
Date
Were you sentenced as a result of these charges?
YES NO
Conviction Detail
Provide a description of the sentence.
Sentence description (Free Text)
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Branch
Were you incarcerated as a result of that sentence for not less than 1 year?
YES NO
If Yes to Being
If the conviction resulted in imprisonment, provide the dates that you
From Date (Estimated)
Sentenced
actually were incarcerated. (Not Applicable □ )
To Date (Estimated/Present)
If the conviction resulted in probation or parole, provide the dates of
From Date (Estimated)
probation or parole. (Not Applicable □)
To Date (Estimated/Present)
Trial detail
Branch
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this
YES NO
If No to Being
offense?
Sentenced
Provide Explanation
Explanation (Free Text)
Do you have any other offenses to list where the following has EVER happened to you?
YES
NO
• Have you EVER been convicted of an offense involving domestic violence or a crime of
(Yes adds
(Required to
violence (such as battery or assault) against your child, dependent, cohabitant, spouse or
another entry)
validate)
legally recognized civil union/domestic partner, former spouse or legally recognized civil
union/domestic partner , or someone with whom you share a child in common?

Is there currently a domestic violence protective order or restraining order issued against you?
YES NO
You responded ‘Yes’ to currently having a domestic violence protective order or restraining order issued against you.
Branch
If Yes to
Provide explanation:
Explanation (Free Text)
Domestic
Provide the date the order was issued.
Date (Estimated)
Violence
Provide the name of the court or agency that issued the order.
Name of court (Free Text)
(Multiple
Provide
the
location
of
the
court
or
agency
that
issued
the
order.
Street address and city
State and Zip Code or Country
Entries
Do you have another domestic violence protective order or
YES
NO
Allowed)
restraining order currently issued against you to report?
(Yes adds another entry)
(Required to validate)

Section 21 – Illegal Use of Drugs and Drug Activity
You are required to answer the questions. We note, with reference to this section, that neither your truthful responses nor information derived from
your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies
whether or not you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled
substances or drug or controlled substance activity not in accordance with Federal laws, even though permissible under state laws.
In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or controlled substance
YES NO
includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.
You answered ‘Yes’ to in the last seven (7) years having illegally used a drug or controlled substance.
Provide the type of drug or controlled substance.
Explanation if other (Free Text)
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Branch
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
If Yes to
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Illegally Using Provide an estimate of the
Date (Estimated)
Provide an estimate of the month Date (Estimated)
Drugs or
month and year of first use.
and year of most recent use.
Controlled
Provide nature of use, frequency, and number of times used.
Nature of use (Free Text)
Substances
Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while
YES NO
in a position directly and immediately affecting the public safety?
(Multiple
Was your use while possessing a security clearance?
YES NO
Entries
Do
you
intend
to
use
this
drug
or
controlled
substance
in
the
future?
YES NO
Allowed)
Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Explanation
(Free Text)
Do you have an additional instance(s) of illegal use of a drug or controlled
YES
NO
substance to enter?
(Yes adds another entry)
(Required to validate)
In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production,
YES NO
transfer, shipping, receiving, handling or sale of any drug or controlled substance?
You answered ‘Yes’ to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation,
trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance.
Provide the type of drug or controlled substance.
If other explanation (Free Text)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Branch
If Yes to
Provide an estimate of the month Date (Estimated)
Provide an estimate of the month and
Date (Estimated)
Illegal Drug
and year of first involvement.
year of most recent involvement.
Activity
Provide nature of and frequency of activity.
Nature of activity (Free Text)
Provide the reason(s) why you engaged in the activity.
Reason(s) (Free Text)
(Multiple
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official,
YES NO
Entries
or while in a position directly and immediately affecting the public safety?
Allowed)
Was your involvement while possessing a security clearance?
YES NO
Do you intend to engage in this activity in the future?
YES NO
You have indicated that you plan to engage in the illegal purchase, manufacture,
Explanation (Free Text)
Branch
If Yes to
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale
Future Activity of a drug or controlled substance in the future. Provide explanation.
Do you have an additional instance(s) of having been involved in the illegal purchase,
YES
NO
manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale (Yes adds
(Required to
of a drug or controlled substance to enter?
another entry)
validate)
In the last seven (7) years, have you illegally used or otherwise been involved with a drug or controlled substance while employed
YES NO
as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public
safety other than previously listed?
You responded ‘Yes’ to having in the last seven (7) years, illegally used, or otherwise been involved with a drug or controlled
substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and
Branch
immediately affecting the public safety other than previously listed.
If Yes to Use
Provide a description of the drugs or controlled substances used and your involvement.
Description (Free Text)
While in Law
Enforcement
Provide the dates of involvement/use.
From Date (Estimated)
To Date (Estimated/Present)
Provide an estimate the number of times you used and/or were involved this drug or
Estimate (Free Text)
(Multiple
controlled substance while employed in this capacity.
Entries
Do you have an additional instance(s) of illegal use or involvement with a drug or controlled
YES
NO
Allowed)
substance while employed as a law enforcement officer, prosecutor, or courtroom official; or
(Yes adds
(Required to
while in a position directly and immediately affecting the public safety to enter?
another entry)
validate)
In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the
YES NO
drugs were prescribed for you or someone else?
You responded ‘Yes’ to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless of
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whether the drugs were prescribed for you or someone else.
If Yes to
Provide the name of the prescription drug that you misused.
Drug names (Free Text)
Misuse of
Provide the dates of involvement in the above.
From Date (Estimated)
To Date (Estimated/Present)
Prescription
Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Reasons (Free Text)
Drugs
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official,
YES NO
or while in a position directly and immediately affecting the public safety?
(Multiple
Was your involvement while possessing a security clearance?
YES NO
Entries
Do you have an additional instance(s) of intentionally engaging in the misuse
YES
NO
Allowed)
of prescription drugs in the last seven (7) years to enter?
(Yes adds another entry) (Required to validate)
In the last seven (7) years, have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use
YES NO
of drugs or controlled substances?
You responded ‘Yes’ to having in the last seven (7) years, have you been ordered, advised, or asked to seek counseling or
Branch
treatment as a result of your illegal use of drugs or controlled substances
If Yes to
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or
Being Ordered
controlled substances? (Check all that apply)
Treatment for
□ An employer, military commander, or employee assistance program
□ A medical professional
the Misuse of
□ A mental health professional
□ A court official / judge
Drugs
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.
Provide explanation
Explanation (Free Text)
Did you take action to receive counseling or treatment?
YES NO
(Multiple
Branch If No
You have indicated that you did not receive treatment. Provide explanation.
Explanation (Free Text)
Entries
to Action Taken
Allowed)
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
Branch
If Yes to Action □ Inhalants (Such as toluene, amyl nitrate, etc.)
Taken
□ Other (Provide explanation):
Explanation (Free Text)
Provide the name of the treatment
Name (Free Text)
provider. (Last name, First name)
Provide the address for this treatment provider. Street address and city
State and Zip Code or Country
Provide a phone number for the treatment provider.
Number/Ext. Time Day Night
Both _ Check box if
International
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
Did you successfully complete the treatment?
YES NO

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Branch If No
You have indicated that you did not successfully
Explanation (Free Text)
to Successful
complete the treatment. Provide explanation.
Treatment
Do you have another instance of having been ordered, advised, or asked to
YES
NO
seek drug or controlled substance counseling or treatment to enter?
(Yes adds another entry) (Required to validate)
In the last seven (7) years, have you voluntarily sought counseling or treatment as a result of your use of a drug or controlled
YES NO
substance?
Voluntary treatment detail
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Branch
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
If Yes to
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Voluntarily
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Seeking
Provide the name of the treatment provider. (Last name, First name)
Name (Free Text)
Treatment for
Provide the address for this treatment provider.
Street address and city
State and Zip Code or Country
the Misuse of
Provide a phone number for the treatment provider.
Number/Ext.
Drugs
Time Day Night Both _ Check
box if International
(Multiple
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
Entries
Did you successfully complete the treatment?
YES NO
Allowed)
Branch If No to
You have indicated that you did not you successfully complete the
Explanation (Free Text)
Successful Treatment treatment. Provide explanation.
Do you have another instance of EVER voluntarily seeking counseling
YES
NO
or treatment as a result of your use of a drug or controlled substance?
(Yes adds another entry)
(Required to validate)

Section 22 – Use of Alcohol
In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your professional
YES NO
relationships, or resulted in intervention by law enforcement/public safety personnel?
You responded ‘Yes’ to your alcohol use having had a negative impact on your work performance, your professional relationships,
or resulted in intervention by law enforcement/public safety personnel.
Provide the month/year when this negative impact occurred.
Date (Estimated)
Provide an explanation of the circumstances and the negative impact.
Provide circumstances (Free Text)
Provide negative impact (Free Text)
Provide dates of involvement or use
From Date (Estimated)
To Date (Estimated/Present)
Has the use of alcohol had other negative impacts on your work performance, your
YES
NO
professional relationships, or resulted in intervention by law enforcement/public safety
(Yes adds
(Required to
personnel?
another entry)
validate)
In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a result of
YES NO
your use of alcohol?
You responded ‘Yes” to having been ordered, advised or asked to seek counseling or treatment as a result of your
use of alcohol.

Branch
If negative
impact
(Multiple
Entries
Allowed)

Branch
If Yes to
having been
ordered,
advised, or
asked to seek
counseling

Did you take action to seek counseling or treatment?

YES

NO

You responded ‘No’ to having taken action to seek counseling
Explanation (Free Text)
or treatment. Explain the reasons for not taking action to seek
counseling or treatment.
Branch If Yes
You responded ‘Yes’ to having taken action to seek counseling or treatment.
to Taking
Provide the dates of counseling or treatment
From Date
To Date
Action
(Estimated)
(Estimated/Present)
Provide the name of the individual counselor or treatment provider Counselor name (Free
(Multiple.
Text)
Entries
Provide the full address of the
Provide telephone number
Number/Ext
Allowed)
counseling/treatment provider.
Time Day
Night Both _
Check box if
International
Street address and city
State and Zip Code or Country
Did you successfully complete the treatment program?
YES NO
Branch If No to
You responded “No” to having successfully
Explanation (Free Text)
Successful
completed the treatment program. Provide
Completion
explanation
Do you have additional instances of having been ordered, advised or asked
YES
NO
to seek counseling or treatment as a result of your use of alcohol to enter?
(Yes adds another entry) (Required to validate)
In the last seven (7) years, have you voluntarily sought counseling or treatment as a result of your use of
YES NO
alcohol?
You responded ‘Yes’ to voluntarily seeking counseling or treatment.
Branch
Provide the dates of counseling or treatment
From Date (Estimated)
To Date (Estimated/Present)
If Yes to
Provide the name of the individual counselor or treatment provider.
Counselor name (Free Text)
to Seeking
Provide the full address of the
Street address and city
State and Zip Code or Country
Counseling
counseling/treatment provider.
(Multiple
Provide
Number/Ext
Did you successfully complete the treatment program?
YES NO
Entries
telephone
Time Day Night
Allowed)
number
Both _ Check box
if International
Branch If No
Action Taken

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
You answered ‘No’ to having
Explanation (Free Text)
successfully completed the treatment
program. Provide explanation:
Do you have additional instances where you have voluntarily sought
YES
NO
counseling or treatment as a result of your use of alcohol to enter?
(Yes adds another entry)
(Required to validate)
Branch If Unsuccessful

Section 23 – Investigations and Clearance Record
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance
YES NO
eligibility/access?
You responded ‘Yes’ to the U.S. Government (or a foreign government) having investigated your background and/or having
granted you a security clearance eligibility/access.
Provide the investigating
□ U.S. Department of Defense
□ U.S. Department of State
agency:
□ U.S. Office of Personnel Management
□ Federal Bureau of Investigation
□ U.S. Department of Treasury (provide name of bureau)
Branch
□ U.S. Department of Homeland Security
Explanation or name of
If Yes to Having
□ Foreign government, (Provide name of government) □ I don’t know
government or bureau (Free
Ever Been
□ Other (Provide explanation)
Text)
Investigated
Date the investigation was completed.
□ I don’t know
Date (Estimated)
Provide the name of agency that issued the clearance eligibility/access if different from the
Name (Free Text)
(Multiple Entries
investigating agency.
Allowed)
Provide the date clearance eligibility/access was granted. □ I don’t know
Date (Estimated)
Provide the level of clearance
□ None
□ Confidential
□ Secret
□ Top Secret
eligibility/access granted.
□ Sensitive Compartmented Information (SCI) □ Q
□L
□ I don’t know
□ Issued by foreign country
□ Other (Provide explanation)
Explanation (Free Text)
Do you have another investigation to enter?
YES (Yes adds another entry)
NO (Required to validate)
Have you EVER had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An administrative
YES NO
downgrade or administrative termination of a security clearance is not a revocation.)
You responded ‘Yes’ to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.
Branch
Provide the date security clearance eligibility/access authorization was denied, suspended or revoked.
Date (Estimated)
If Yes to Denied
Provide the name of the agency that took the action.
Name (Free Text)
Provide an explanation of the circumstances of the denial, suspension or revocation action.
Explanation (Free Text)
(Multiple Entries
Do you have another denied, revoked or suspended security
YES
NO
Allowed)
clearance eligibility/access authorization to enter?
(Yes adds another entry) (Required to validate)
Have you EVER been debarred from government employment?
YES
NO
You responded ‘Yes’ to having EVER been debarred from government employment.
Branch
Provide the name of the government agency taking debarment action.
Agency name
If Yes to
Debarment
Provide the date the debarment occurred.
Date (Estimated)
(Multiple Entries
Provide an explanation of the circumstances of the debarment
Circumstances (Free text)
Allowed)
Do you have another Government debarment to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 24 – Financial Record
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
YES
NO
You responded ‘Yes’ to having filed a petition under any chapter of the bankruptcy code.
Select the applicable bankruptcy petition type:
□ Chapter 7 □ Chapter 11 □ Chapter 12 □ Chapter 13
Provide the bankruptcy court docket/account number.
Account Number (Free Text)
Provide the date bankruptcy was filed.
Date (Estimated)
Provide date of bankruptcy discharge. □ Not Applicable
Date (Estimated)
Branch
Provide the total amount (in U.S. dollars) involved in the bankruptcy. □ Estimated
Amount (Free Text)
If Yes to
Having Filed
Provide the name debt is recorded under.
Last
First
Middle
Suffix
Bankruptcy
Provide the name of the court involved.
Court Name (Free Text)
Provide the address of the court involved.
Street address and City
State and Zip Code or Country
(Multiple
Provide the name of the trustee for this bankruptcy.
Name (Free Text)
Branch
Entries
If Chapter 13 Provide the address of the trustee for this bankruptcy.
Allowed)
or Chapter
Street address and City
State and Zip Code or Country
12
Were you discharged of all debts claimed in the bankruptcy? Provide Explanation
Explanation (Free Text)
YES
NO
In the last seven (7) years, have you filed any additional petitions under any
YES
NO
chapter of the bankruptcy code?
(Yes adds another entry) (Required to validate)
In the last seven (7) years have you failed to meet financial obligations due to gambling?
YES
NO
You responded ‘Yes’ to in the last seven (7) years have you experienced financial problems due to gambling.
Branch
If Yes to
Provide the date range of your financial problems due to gambling.
From Date (Estimated)
To Date (Estimated/Present)
Financial
Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.
Amount
(Free Text)
Problems Due
Provide a description of your financial problems due to gambling.
Description (Free Text)
to Gambling
If you have taken any action(s) to rectify your financial problems due to gambling, provide a
Description (Free Text)
(Multiple
description of your actions. If you have not taken any action(s) provide explanation.
Entries
In the last seven (7) years have failed to meet other financial
YES (Yes adds another entry)
NO (Required to validate)
Allowed)
obligations due to gambling?
In the pastlast seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?
YES
NO
You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Branch
Did you fail to file, pay as required, or both? □ File □ Pay □ Both
Provide the year you failed to file or pay your Federal, state or other taxes.
If Yes to
Failing to
Provide the reason(s) for your failure to file or pay required taxes.
Reasons (Free Text)
File/Pay Taxes Provide the Federal, state or other agency to which you failed to file or pay taxes.
Agency (Free Text)
Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.).
Tax Type (Free Text)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Provide the amount (in U.S. dollars) of the taxes. □ Estimated
Amount (Free Text)
Provide date satisfied. □ Not applicable
Date (Estimated)
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Are there any other instances in the pastlast seven (7) years where you
YES
NO
failed to file or pay Federal, state or other taxes when required by law or
(Yes adds another entry) (Required to validate)
ordinance?
In the pastlast seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement for a travel or
YES
NO
credit card provided by your employer?
You responded ‘Yes’ to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit
Branch
card provided by your employer.
Provide the name of the agency or company.
Agency (Free Text)
If Yes to
Provide the address of the agency or company.
Street address and City
State and Zip Code or Country
Violation of
Provide the reason(s) for the counseling, warning or disciplinary action.
Reasons (Free Text)
Credit/Travel
Provide the amount (in U.S. dollars) of violation. □ Estimated
Amount (Free Text)
Card Terms
Provide a description of any action(s) you have taken to rectify this situation. If you have not
Description (Free Text)
taken any action(s) provide explanation.
(Multiple
Are there any other instances in the past last seven (7) years where you have been counseled,
YES
NO
Entries
warned,
or
disciplined
for
violating
the
terms
of
agreement
for
a
travel
or
credit
card
provided
(Yes
adds
(Required to
Allowed)
by your employer?
another entry)
validate)
Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve an inability to
YES
NO
meet financial obligations?
You responded ‘Yes’ to currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to
Branch
resolve an inability to meet financial obligations.
Provide explanation (Free Text)
Provide the name of the credit counseling organization or resource.
Name (Free Text)
If Yes to
Provide the phone number of the credit counseling organization.
Number / Ext
Seeking Credit
Provide the location of the credit counseling organization.
City
State
Counseling
As a result of this counseling provide a description of any action(s) you have taken to
Description (Free Text)
resolve your inability to meet financial obligations. If you have not taken any action(s)
(Multiple
provide explanation.
Entries
Are you currently utilizing, or seeking assistance from any other credit counseling service
YES (Yes adds
NO (Required
Allowed)
or other similar resource to resolve your inability to meet financial obligations?
another entry)
to validate)
Other than previously listed, have any of the following happened to you? (You will be asked to provide details about each financial obligation that
pertains to the items identified below).
• You are currently delinquent on alimony or child support payments.
• In the pastlast seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well
as those for which you were a cosigner or guarantor).
• In the pastlast seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you
are a cosigner or guarantor).
YES NO
You answered ‘Yes’ to having experienced one or more of the previously stated financial issues.
Provide the name of agency/organization/individual to which debt is/was owed
Name (Free Text)
Did/does this financial issue include any of the following: (Check all that apply)
□ You are currently delinquent on alimony or child support payments.
□ In the pastlast seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
□ In the pastlast seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include
Branch
financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
□ You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as
If Yes to
those for which you are a cosigner or guarantor).
Having
YES NO
Financial
Provide the associated loan / account number(s) involved
Loan / account number (Free Text)
Issues
Identify/describe the type of property involved (if any).
Property type (Free Text)
Involving
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated
Amount (Free Text)
Enforcement
Provide the reason(s) for the financial issue.
Reasons (Free Text)
Provide the current status of the financial issue.
Status (Free Text)
(Multiple
Provide the date the financial issue began.
Date (Estimated)
Entries
Provide
date
the
financial
issue
was
resolved.
□
Not
resolved
Date (Estimated)
Allowed)
Provide the name of the court involved.
Court name (Free Text)
Provide the address of the court involved.
Street address and City
State and Zip Code or Country
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
frequency and amount of payments, etc.). If you have not taken any provide explanation.
Other than previously listed, are there any other instances of the following occurrences?
• You are currently delinquent on alimony or child support payments.
• In the pastlast seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
• In the pastlast seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include
financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as
those for which you are a cosigner or guarantor).
YES (Yes adds another entry)
NO (Required to validate)
(Multiple
Entries
Allowed)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Other than previously listed, have any of the following happened?
• In the pastlast seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)
• In the pastlast seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as
those for which you were a cosigner or guarantor)
• In the pastlast seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor)
• In the pastlast seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include
financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)
• In the pastlast seven (7) years, you were evicted for non-payment?
• In the pastlast seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason?
• In the pastlast seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or guarantor)
• You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which
you are a cosigner or guarantor)
YES NO
You answered ‘Yes’ to having experienced one or more of the previously stated financial issues.
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following: (Check all that apply)
□ In the pastlast seven (7) years you had your possessions or property voluntarily or involuntarily repossessed or foreclosed.
(Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
□ In the pastlast seven (7) years you defaulted on any type of loan. (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor).
□ In the pastlast seven (7) years you had bills or debts turned over to a collection agency. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor).
□ In the pastlast seven (7) years you had an account or credit card suspended, charged off, or cancelled for failing to pay as
agreed. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or
guarantor).
□ In the pastlast seven (7) years you were evicted for non-payment.
□ In the pastlast seven (7) years you had wages, benefits, or assets garnished or attached for any reason.
□ In the pastlast seven (7) years you were over 120 days delinquent on any debt not previously entered. (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
□ You are currently over 120 days delinquent on any debt. (Include financial obligations for which you are the sole debtor, as well
as those for which you are a cosigner or guarantor).
YES NO
Provide the associated loan / account number(s) involved.
Loan / account number (Free Text)
Branch
Identify/describe the type of property involved (if any).
Property type (Free Text)
If Yes to
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated
Amount (Free Text)
Having
Provide the reason(s) for the financial issue.
Reasons (Free Text)
Financial
Provide the current status of the financial issue.
Status (Free Text)
Issues
Provide date the financial issue was resolved. □ Not resolved
Date (Estimated)
Involving
Provide the date the financial issue began.
Date (Estimated)
Routine
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
Accounts
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Other than previously listed, are there any other instances of the following occurrences?
(Multiple
□ Yes □ No
Entries
• In the pastlast seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed.
Allowed)
(include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
• In the pastlast seven (7) years, you defaulted on any type of loan, (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor).
• In the pastlast seven (7) years, you had bills or debts turned over to a collection agency. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor).
• In the pastlast seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as
agreed. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or
guarantor).
• In the pastlast seven (7) years, you have been evicted for non-payment.
• In the pastlast seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason.
• In the pastlast seven (7) years, you have been over 120 days delinquent on any debt not previously entered. (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
• You are currently over 120 days delinquent on any debt. (Include financial obligations for which you are the sole debtor, as well
as those for which you are a cosigner or guarantor).
YES (Yes adds another entry)
NO (Required to validate)

Section 25 – Use of Information Technology Systems
We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used
as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by
the Federal government. The following questions ask about your use of information technology systems. Information technology systems include all
related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection
of information.
In the last seven (7) years have you illegally or without proper authorization accessed or attempted to access any information
YES NO
technology system?
You responded ‘Yes’ to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter
Branch
into any information technology system.
If Yes to
Provide the date of the incident
Date (Estimated)
Unauthorized
Access
Provide a description of the nature of the incident or offense.
Description of incident (Free Text)
Provide the location where the incident took place.
Street address and City
State and Zip Code or Country

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
(Multiple
Provide a description of the action (administrative, criminal or other) taken as a result of
Description (Free Text)
Entries
this incident.
Allowed)
Are there any other incidents to report?
YES (Yes adds another entry)
NO (Required to validate)
In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or denied others access to
YES NO
information residing on an information technology system or attempted any of the above?
You responded ‘Yes’ to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or
Branch
denied others access to information residing on an information technology system or attempted any of the above.
If Yes to
Provide the date of the incident
Date (Estimated)
Manipulating
Provide a description of the nature of the incident or offense.
Description of incident (Free Text)
Access
(Multiple
Provide the location where the incident took place.
Street address and City
State and Zip Code or Country
Entries
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Description (Free Text)
Allowed)
Are there any other incidents to report?
YES (Yes adds another entry)
NO (Required to validate)
In the last seven (7) years have you introduced, removed, or used hardware, software, or media in connection with any information
YES NO
technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted
any of the above?
You responded ‘Yes’ to having in the last seven (7) years introduced, removed, or used hardware, software, or media in
Branch
connection with any information technology system without authorization, when specifically prohibited by rules, procedures,
If Yes to
guidelines, or regulations or attempted any of the above.
Unlawful Use
Provide the date of the incident
Date (Estimated)
Provide a description of the nature of the incident or offense
Description (Free Text)
(Multiple
Provide the location where the incident took place.
Street address and City
State and Zip Code or Country
Entries
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Description (Free Text)
Allowed)
Are there any other incidents to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 26 – Involvement in Non-Criminal Court Actions
In the last seven (7) years, have you been a defendant in party to any public record civil court action (s) not listed elsewhere on
YES
NO
this form? alleging fraud or intentional tortuous conduct?
You responded ‘Yes’ to having been a defendant in party to any public record civil court action (s) not listed elsewhere on this
Branch
form alleging fraud or intentional tortious conduct in the last seven (7) years.
If Yes to
Provide the date of the civil action
Date (Estimated)
Provide the court name
Court name (Free Text)
Having Non
Provide the address of the court
Street address and City
State and Zip Code or Country
Criminal
Provide details of the nature of the action
Details (Free Text)
Court Actions
Provide a description of the results of the action
Results (Free Text)
(Multiple
Provide the name(s) of the principal parties involved in the court action.
Names (Free Text)
Entries
Are there any other civil court actions in the last seven (7) years to report?
YES
NO
Allowed)
(Yes adds another entry) (Required to validate)

Section 27 – Association Record
The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds
for an adverse employment or, credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence
or are dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by
intimidation or coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.
Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the
YES NO
organization’s dedication to that end, or with the specific intent to further such activities?
You responded ‘Yes’ to being or EVER having been a member of an organization dedicated to terrorism, either with an
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awareness of the organization’s dedication to that end, or with the specific intent to further such activities.
Provide the full name of the organization.
Organization name (Free Text)
If Yes to Being a
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Member of a
Provide the dates of your involvement with the organization.
From Date (Estimated)
To Date (Estimated/Present)
Terrorist
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Organization
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
Provide
a
description
of
the
nature
of
and
reasons
for
your
involvement
with
the
organization.
Involvement (Free Text)
(Multiple Entries
Do you have any other instances of being a member of an organization dedicated to
YES
NO
Allowed)
terrorism, either with an awareness of the organization’s dedication to that end, or with the
(Yes adds
(Required to
specific intent to further such activities to report?
another entry)
validate)
Have you EVER knowingly engaged in any acts of terrorism?
YES NO
Branch If Yes
You responded ‘Yes’ to EVER having knowingly engaged in any acts of terrorism.
Engaging in
Describe the nature and reasons for the activity.
Nature and reasons (Free Text)
Terrorism
Provide the dates for any such activities
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of knowingly engaging in acts of
YES
NO
Allowed)
terrorism to report?
(Yes adds another entry)
(Required to validate)
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?
YES
NO
You responded ‘Yes’ to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government
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by force.
If Yes to
Provide the reason(s) for advocating acts of terrorism.
Reasons (Free Text)
Advocating
Provide the dates of advocating acts of terrorism
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of advocating acts of terrorism or activities
YES (Yes adds
NO (Required to
Allowed)
designed to overthrow the U.S. Government by force to report?
another entry)
validate)
Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States
YES NO
Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the
specific intent to further such activities?
You responded ‘Yes’ to having EVER been a member of an organization dedicated to the use of violence or force to overthrow
Branch
the United States Government, and which engaged in activities to that end with an awareness of the organization’s dedication to
that end or with the specific intent to further such activities.
If Yes to being
Member of
Provide the full name of the organization.
Organization name (Free Text)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Organization
Using Violence
to Overthrow the
U.S. Govt.

Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Provide the dates of your involvement with the organization
From Date (Estimated)
To Date (Estimated/Present)
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
Provide a description of the nature of and reasons for your involvement with the organization.
Description (Free Text)
(Multiple Entries
Do you have any other instances of being a member of an organization dedicated to the use
YES
NO
Allowed)
of violence or force to overthrow the United States Government, which engaged in
(Yes adds
(Required to
activities to that end with an awareness of the organization’s dedication to that end or with
another entry)
validate)
the specific intent to further such activities to report?
Have you EVER been a member of an organization that advocates or practices commission of acts of force or violence to
YES NO
discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to
further such action?
You responded ‘Yes’ to being or EVER having been a member of an organization that advocates or practices commission of
acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the
U.S. with the specific intent to further such action.
Provide the full name of the organization.
Organization Name (Free Text)
Branch
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
If Yes to Being a
Provide the dates of your involvement with the organization
From Date (Estimated)
To Date (Estimated/Present)
Member of
Organization
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Using Violence
Provide all contributions (in U.S. dollars) made to the organization, if any. □ No contributions
Contributions (Free Text)
made
(Multiple Entries
Provide a description of the nature of and reasons for your involvement with the organization.
Involvement (Free Text)
Allowed)
Do you have any other instances of being a member of an organization that advocates or
YES
NO
practices commission of acts of force or violence to discourage others from exercising
(Yes adds
(Required to
their rights under the U.S. Constitution or any state of the United States with the specific
another entry)
validate)
intent to further such action to report?
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?
YES
NO
Branch If Yes to You responded ‘Yes’ to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Describe the nature and reasons for the activity.
Reasons (Free Text)
Activities to
Overthrow
Provide the dates of such activities.
From Date (Estimated)
To Date Estimated/Present)
(Multiple Entries
Do you have any other instances of having knowingly engaged in activities YES
NO
Allowed)
designed to overthrow the U.S. Government by force to report?
(Yes adds another entry) (Required to validate)
Have you EVER associated with anyone involved in activities to further terrorism?
YES
NO
Branch If Yes to
Terrorism Association Detail
Having
Provide Explanation
Explanation (Free Text)
Terrorism
Association
Additional Comments
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate,
and then sign and date the following certification and the attached release(s).
Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in
good faith. I further affirm that, to the best of my knowledge, I have not included any classified information herein. I have carefully read the
foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine or
imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying, or including classified
information may have a negative effect on my, employment prospects, or job status, or my removal and debarment from Federal service.
Signature

Date (mm/dd/yyyy)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation or reinvestigation to obtain any information relating to my activities,
conduct and character from individuals, schools, residential management agents, employers, criminal justice
agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other
sources of information. This information may include, but is not limited to, current and historicmy academic,
residential, achievement, performance, attendance, disciplinary, employment history, criminal, history record
information, and financial and credit information, and publicly available social media information.. I authorize the
Federal agency conducting my investigation, or reinvestigation, or performing continuous vetting, to disclose the
record of my background investigation to the requesting agency for the purpose of making a determination of
suitability or eligibility for a public trust position.
I Understand that, for these purposes, publicly available social media information includes any electronic
social media information that has been published or broadcast for public consumption, is available on request
to the public, is accessible on-line to the public, is available to the public by subscription or purchase, or is
otherwise lawfully accessible to the public. I further understand that this authorization does not require me
to provide passwords; log into a private account; or take any action that would disclose non-publicly
available social media information.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name,
Social Security Number, and date of birth with information in SSA records and provide the results of the match) to
the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my
investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the
other Federal agency requesting or conducting my investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and
other sources of information, a separate specific release may be needed, and I may be contacted for such releases at
a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau
of Investigation, the Department of Defense, the Department of Homeland Security, and the Department of State,
and any other authorized Federal agency, to request criminal record information about me from criminal justice
agencies for the purpose of determining my eligibility for assignment to, or retention in, a public trust position, in
accordance with 5 U.S.C. 9101. I understand that I may request a copy of such records as may be available to me
under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of any Federal agency
authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by
the Federal Government only for the purposes provided in this Standard Form 85P, and that it may be disclosed by
the Government only as authorized by law.
I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and
analyses, which will be maintained in accordance with the Privacy Act.
Photocopies of this authorization with my signature are valid. This authorization is valid for five (5) years from the
date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.

Signature
Other names used

Full name (Type or print legibly)
Date of birth

Date signed (mm/dd/yyyy)
Social Security Number

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
Current street address Apt. #

City (Country)

State

ZIP Code

Home telephone number

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA)
If you answered “Yes” to Section 5 of the Standard Form 85P with the supplemental SF 85P-S, carefully read this
authorization to release information about you, then sign and date.
This is an authorization for the investigator to ask your health practitioner (s) the questions below concerning your
mental health consultations. The U.S. government recognizes the critical importance of mental health and advocates
proactive management of mental health conditions to support the wellness and recovery of Federal employees and
others. The government recognizes that mental health counseling and treatment may provide important support for
those who have experienced traumatic events, as well as for those with other mental health conditions. While most
individuals with mental health conditions do not present risks, there may be times when such a condition can affect a
person’s suitability for positions of public trust with the Federal government. Seeking or receiving mental health
care for personal wellness and recovery may contribute favorably to your suitability determination. Your signature
will allow the practitioner (s) to answer only those questions identified below.
Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) only the specific questions below concerning
any mental health consultations of which the practitioner might be aware. Your signature will allow the
practitioner(s) to answer only these questions. Should additional information be required from the health care
practitioner, a separate specific release is needed, and you may be contacted for such a release at a later date.
If you are completing the SF 85P, this release will be required in the event information arises in an investigation that
requires such further inquiry for resolution and only to resolve such issues.
If you are completing the SF 85P with the supplemental SF 85P-S, this release is required if you respond “yes” to
the question regarding Your Medical Record.
Authorization
I am seeking assignment to or retention in a public trust position. As part of the investigation process, I hereby
authorize the investigator, special agent, or duly accredited representative of the authorized Federal agency
conducting my background investigation, reinvestigation, and my health practitioner (s) to provide the information
requested below, to obtain the following information relating to my mental health consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to
my health care provider/entity.the U.S. Office of Personnel Management. I understand that I may revoke this
authorization except to the extent that action has already been taken based on this authorization. Further, I
understand that this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
I understand the information disclosed pursuant to this authorizationrelease is for use by the Federal Government
only for purposes provided in the Standard Form 85P and that it may be disclosed by the Government only as
authorized by law, but will no longer be subject to the HIPAA Pprivacy Rrule, and that the Federal Government may
redisclose the information as authorized by law, subject to Privacy Act safeguards.
Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the
date signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)

Full name (Type or print legibly)

Other names used
Current street address Apt. #

City (Country)

State

Date signed (mm/dd/yyyy)

Date of birth

Social Security Number

ZIP Code

Home Ttelephone number

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
For Use By Practitioner(s) Only
Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to
perform a position of public trust?
__YES __NO
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
Dates of treatment?
Signature (Sign in ink)

Practitioner name

Date signed (mm/dd/yyyy)

v.3 DRAFT PRE-DECISIONAL DELIBERATIVE
QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS
UNITED STATES OF AMERICA
FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment
purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
Information provided by you on this form will be furnished to the consumer reporting agency in
order to obtain information in connection with a background investigation to determine your (1)
fitness for Federal employment, (2) ability to perform contractual service for the Federal
government, and/or (3) eligibility for a public trust position.
The information obtained may be disclosed to other Federal agencies for the above purposes in
fulfillment of official responsibilities to the extent that such disclosure is permitted by law.
Information from the consumer report will not be used in violation of any applicable Federal or
state equal employment opportunity law or regulation.
Authorization
I hereby authorize any investigator, special agent, or other duly accredited representative of the
authorized Federal agency conducting my initial background investigation and reinvestigation, or
my eligibility for a public trust position, to request, and any consumer reporting agency to
provide, the investigative agency conducting my background to obtain such reports from any
consumer reporting agency for employment purposes described above.
Note: If you have a security freeze on your consumer or credit report file, then we willmay not
be able to access the information necessary to completecomplete your investigation, which can
adversely affect your eligibility for a public trust position. To avoid such delays, you should
expeditiously respond to any request made to release the credit freeze for the purposes as
described above.may want to consider requesting that the consumer reporting agencies lift the
freeze in these instances.
Your Social Security Number (SSN) is needed to identify your unique records. Although
disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the
processing of your background investigation. The authority for soliciting and verifying your SSN
is Executive Order 9397.
Photocopies of this authorization with my signature are valid. This authorization shall remain in
effect so long as I occupy a public trust position.
Print name

Social Security Number

Signature

Date (mm/dd/yyyy)