DOE F 5631.5 Security Interviews

DOE F 5631.5
(05/98/Administrative Update 03/2011)
All Editions Prior to 05/98 Are Obsolete

U.S. Department of Energy

The Conduct of Personnel Security Interviews
Under DOE Security Regulations

OMB Control No.
1910-1800
OMB Burden Disclosure
Statement on Reverse

The U.S. Department of Energy (DOE) has received information which has been evaluated as raising a doubt
regarding your eligibility for access authorization. This interview is authorized to afford you an opportunity to furnish
an explanation of such information. If a substantial doubt still exists regarding your eligibility for access
authorization after consideration of the investigative record, as well as the explanation provided by you during or
subsequent to this interview, you will be given the opportunity to appear before a Hearing Officer in accordance
with DOE Administrative Review Procedures. Any information furnished by you during or subsequent to this
interview which has a bearing on your access eligibility may be used by DOE.
The provisions of Section 1001, Title 18, U.S. Code, are applicable in connection with DOE interview procedures.
Title 18, U.S. Code
Section 1001, Title 18, U.S. Code (False Statements within Jurisdiction of Government Agency, etc.) and to a
Government Representative.
“Whoever, in any matter within the jurisdiction of any department or agency in the United States knowingly and
willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false,
fictitious, or fraudulent statements or representations, or makes or uses any false writing or document knowing the
same to contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or
imprisoned not more that five years, or both.”
It is DOE policy to record the interview and prepare either a written interview transcript or interview summary which
will be made a permanent part of your DOE Personnel Security File. If you want a copy of the interview transcript,
a copy will be furnished to you at your verbal or written request. You must indicate the address to which the
transcript is to be sent. Your decision not to request a copy of the interview transcript at this time does not preclude
you from requesting, and being provided, a copy in the future. A copy cannot be provided in the future if your
Personnel Security File has been destroyed (files are maintained for 10 years after termination of access
authorization or processing for access authorization if access authorization is not granted). This form which you are
asked to sign will be made a part of the official transcript of this interview for future reference and use by the DOE.
Please review the “Privacy Act Information Statement” on the reverse of this form.

Certification:
I hereby acknowledge that I have read and understand the above reasons for conducting this interview
and consent to the interview being recorded and to a transcript or summary being prepared of these
proceedings.
Signature

Date

18 U.S.C. SECTION 1001; ACT OF JUNE 25, 1948; 62 STAT. 749; MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT
OR PRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTERS WITHIN ITS JURISDICTION.

DOE F 5631.5
(05/98/Administrative Update 03/2011)
All Editions Prior to 05/98 Are Obsolete

OMB Control No.
1910-1800

PRIVACY ACT INFORMATION STATEMENT
Collection of the information requested is authorized under Title 10, Code of Federal Regulations, Part 710 and
DOE 470.4-5, “Personnel Security.” Participation in the Conduct of a Personnel Security Interview (PSI) is
voluntary, however, your decision not to participate in a PSI (or complete this form) may result in the discontinuation
of processing your case for access authorization (security clearance) or the termination of your current access
authorization. A transcript of the PSI Summary and this form will be made a permanent part of your DOE Personnel
Security File (PSF). Access to your PSF within the DOE and by other individuals is permitted as stipulated in DOE
M 470.4-5 and as listed as Routine Users in Systems of Records DOE-43, “Personnel Security Clearance Files”. A
copy of this signed form will be provided to you at your verbal or written request. You must designate the address to
which a copy of the form is to be sent.

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including
the 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 this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to the Office of Health,
Safety and Security’s Office of Departmental Personnel Security (HS-1.4), U.S. Department of Energy, 1000
Independence Avenue, S.W., Washington, D.C. 20585; and to the Office of Information and Regulatory Affairs,
Office of Management and Budget (OMB), Washington, D.C. 20503.

18 U.S.C. SECTION 1001; ACT OF JUNE 25, 1948; 62 STAT. 749; MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT
OR PRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTERS WITHIN ITS JURISDICTION.