DOE F 470.5 HRP Consent Release

OMB Control No. 1910-5122

DOE F 470.5
(05-2016)
All other editions obsolete

U.S. Department of Energy
OMB Disclosure Statement
Public reporting burden for this collection of information is estimated to average two 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 Environment, Health, Safety and Security, AU-1.2, FSTL, GTN, Paperwork Reduction Project
(1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585-1290; and to the Office of Management
and Budget (OMB), Paperwork Reduction Project (1910-5122), Washington, DC 20503.

AUTHORIZATION AND CONSENT TO RELEASE HUMAN RELIABILITY
PROGRAM (HRP) RECORDS IN CONNECTION WITH HRP
1.

I,
(print applicant’s/employee’s full name) am a candidate for
occupying or continuing to occupy an HRP-identified position.

2.

I understand that the HRP certification process will generate medical and non-medical records
(hereinafter “HRP records”) relevant to my eligibility to occupy an HRP position. I recognize that
these HRP records are protected by the Privacy Act of 1974, as amended.

3.

For purposes of this consent, my HRP records include, but are not limited to, any records generated
by a pre-employment check performed by either
(DOEcontractor’s corporatename, hereinafter “Corporation”) or the Department of Energy (DOE):
medical records, including but not limited to, medical histories, results of medical examinations,
results of psychological examinations and/or tests; results of urine tests taken to determine the
presence of illegal drugs in my body; and the results of an alcohol breathalyzer test.

4.

I hereby consent that any of the HRP records within the coverage of paragraph 3 may be disclosed to
the appropriate Corporation management and DOE officials who have a legitimate need for the
records in the performance of their duties and responsibilities in the HRP review and approval
process.

5.

I acknowledge that such disclosure in connection with the HRP is an approved disclosure in
accordance with 5 USC §552a(b)(1). I further agree that this document will serve as written consent
to the disclosure of the HRP records to the appropriate Corporation management and DOE officials
within the meaning of the Privacy Act.

6.

I further waive any rights and release the Corporation, DOE, and any and all individuals employed
by the corporation or DOE, including DOE contractor medical department personnel, from liability
under the Privacy Act, 5 USC §552a, the U.S. or state constitutions, any other applicable federal or
state statutes, any applicable physician-patient privilege, and common law claims of any nature
whatsoever, for disclosure of my HRP records to Corporation management or DOE officials with a
legitimate need for the records in the performance of their responsibilities in the HRP review and
certification process.

7.

My signature below acknowledges that I have read and understand the foregoing authorization and
consent agreement.

Date

Employee (Signature)

HRP Management Official (Print Name and Signature)
Privacy Act Statement
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE) to regulate the
possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to aid in the determination of an
individual=s eligibility for an HRP certification. The information may also be provided to other agencies of the United States government for investigations that involve
protection of the national security, public health and safety, or the environment. Submission of the information requested on this form is voluntary, but failure to
provide the information may result in denial of an HRP certification. If DOE uses the information for purposes other than those indicated in this statement, it will
provide notice of those additional purposes to persons who have submitted information on this form.