Form DOE F 531 DOE F 531 PRIVACY ACT INFORMATION REQUEST

OMB Control No. 1910-1700 Exp.
Date XX/XX/2020
OMB Disclosure Statement on Back

DOE F 531
(04/2017)
Replaces DOE F 1800.1 (11/1996)
All Other Editions are Obsolete

U.S. DEPARTMENT OF ENERGY

PRIVACY ACT INFORMATION REQUEST
(NOTE: Use of this form is recommended, but is not mandatory)
To request Information or to amend records covered by the Privacy Act of 1974, please complete the appropriate Items in Part I and establish identity in accordance
with instructions on Reverse Side of this form. Retain a copy for your records. Submit signed and completed Privacy Act Request Information form and a copy of
identification to the U.S. Department of Energy Privacy Act Office in accordance with instructions on Reverse side of this form. Requests may also be
submitted to a Privacy Act Officer at a Field Location or National Lab. NOTE: Records will be provided in Adobe PDF format and copied to a CD-ROM unless
the requester states a preference for paper copies.
Part II is For Agency Use Only. FALSE STATEMENTS SUBJECT TO CRIMINAL PENALTIES. PLEASE SEE REVERSE SIDE.

PART I - REQUESTER (Please Print)
Action Requested:

Access

Amendment

Copies

Correction

Full name of requester:

Requester’s Relationship to the individual who is the subject of the records
Parent of a Minor
Legal guardian
Third-party representative authorized by the individual
Member of Congress ________________________________
(name and state)

Name of individual whose record(s) are requested:

Requester’s Mailing Address:

Program Office, Staff Office, Field Site or Lab that you are requesting records
from:

Preferred Method of Contact:
Requester’s Telephone No. (Include Area Code):
Requester’s Email:

Date of Request:

Requester’s Social Security Number (SSN):

Check the type of records you are requesting:
Personnel Security Clearance Files

Payroll/Leave Records

Administrative Review Files

Training Records

Grievance Files

Medical

Personnel Records

X-Ray Reports

Radiation Exposure Report

Occupational and Industrial Records

Other

If “other” is checked, please describe the type of records you are requesting:
Is there a range of dates that should be examined for records?: _______

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

to _______

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

PART II - FOR AGENCY USE ONLY
Proof of Identity witnessed in person before: (Name, Title, Location):
Form of Identity:
Driver’s License
Passport
_____________________

Case Number:
Action assigned to/ Date:
Due Date of Response to Requester:

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

OMB Disclosure Statement
Public reporting burden for this collection of information is estimated to average .33 hours per response,
including the time for reviewing instructions. Send comments regarding this estimate or any other aspect of
this information, including suggestions for reducing this burden, to Chief Privacy Officer (IM-23), Office of
the Chief Information Officer, U.S. Department of Energy, Washington, DC 20595; and to the Office of
Management and Budget (OMB), Paperwork Reduction Project (1910-1700), Washington, DC 20503.
Section 5 USC 55a (i) – Criminal Penalties:
(1) Any officer of employee of an agency, who by virtue of his employment or official position, has possession
of, or access to , agency records which contain individually identifiable information the disclosure of which is
prohibited by this section or by rules or regulations established there under, and who knowing that
disclosure of this specific materials is so prohibited, willfully disclosures the material in any manner to any
person or agency not entitled to receive it, shall be guilty of a misdemeanor and fined not more than $5,000.
(2) Any officer of employee of any agency who willfully maintains a system of records without meeting the notice
requirements of subsection (e) (4) of this section shall be guilty of a misdemeanor and fined not more than
$5,000.
(3) Any person who knowingly and willfully requests or obtains any record concerning an individual form an
agency under false pretenses shall be guilty of a misdemeanor and fined not more than $5,000.
Other Penalties:
A person who falsely or fraudulently attempts to obtain records under the Privacy Act, Title5 U.S.C. Section 55a,
may also be subject to prosecution under other criminal statues such as 18 U.S.C. 494,495, and 1001.
Ways to Submit a Privacy Act request:
(1) By Mail: The U.S. Department of Energy, Privacy Act Request Office, Room GB-172/FORS, 1000
Independence Avenue, S.W., Washington, D.C. 20585; or
(2) By Fax: 202-586-8151 Attn: Privacy Act Request.
(3) At a DOE Field Location: Individuals may make arrangements with the appropriate Privacy Act Officer to
submit a Privacy Act request at a Field Office or National Lab location. Contact information for local Privacy
Act Officers may be accessed here: [link]
Establishing Valid Identification of Individual Making Request Under the Privacy Act:
Pursuant to 10 CFR, § 1008.4 (b) (1) and (b) (2), an individual making a request may establish identity by:
(1) Including with the request, if submitted by mail, a photocopy of two identifying documents bearing name and
signature, one of which shall bear current home or business address and date of birth; or
(2) Appearing at the appropriate DOE Headquarters of Field location during business hours and presenting
either of the following:
(i) One identifying document bearing the individual’s full name, photograph, and signature; or
(ii) Two identifying documents bearing the individual’s full name and signature, one of which shall
bear their current home or business address and date of birth.
(3) If the individual making the request is unable to produce satisfactory evidence of identity, the individual
making the request may be required by the Privacy Act Officer to submit a notarized statement attesting to
his identity and his understanding of the criminal penalties provided under section 1001 of title 18 of the
United States Code for making false statements to a Government agency and under subsection (i) (3) of the
Act for obtaining records under false pretenses.

Privacy Act Statement
Authority: The Privacy Act of 1974 (5 U.S.C. § 552a) and 10 CFR § 1008.7 authorizes the collection of this
information. The information provided through this form is covered by a DOE Privacy Act system of record,
DOE-55, Freedom of Information and Privacy Act (FOIA/PA) Request for Records, which is located in volume
74 of the Federal Register, pages 1059-1061, published on January 9, 2009.
Purpose: DOE will use this information to search for records pertaining to a specific individual when a
Privacy Act information request is submitted by that individual or by an authorized representative on behalf
of that individual.
Routine Uses: This information will be used by and disclosed to DOE personnel, contractors, or another
federal agency who will need the information to locate records responsive to your request. DOE may
disclose this information in courts or in administrative proceedings, to the tribunals, counsel, other parties,
witnesses, and the public (in publicly available pleadings, filings, or discussion in open court) if the
disclosure is relevant and necessary for the proceeding and compatible with the purpose for which the
Department originally collected this information. Additionally, this information may also be disclosed to
members of Congress making requests on behalf of a constituent. This information may be provided to DOE
employees or contracts who have a need for the information in the performance of their duties or to fulfill
contact requirements, pursuant to the purpose established in DOE-55.
Disclosure: Furnishing this information (including additional identifying data) is voluntary; however, failure
to furnish the requested information may delay or increase of difficulty of locating records responsive to
your request.