Form SF 85 P-S SF 85 P-S SUPPLEMENTAL QUESTIONNAIRE FOR SELECTED POSITIONS

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

INSTRUCTIONS
This form is supplemental to SF 85P, Questionnaire for Public Trust
Positions, but is used only after an offer of employment has been made
and when the information it requests is job-related and justified by
business necessity. Other than this restriction to its use, this form has the
same purposes and authorities described on SF 85P. The agency which
gave you this form will tell you which questions to answer.
Instructions for completing this form are the same as SF 85P.

PUBLIC BURDEN INFORMATION: Public burden reporting for this
collection of information is estimated to average 10 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 Reports and Forms Management
Officer, U.S. Office of Personnel Management, 1900 E Street, N.W.,
Room CHP-500, Washington DC 20415. Do not send your completed
form to this address.

Section 1 - Full Name (Enter your full name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions.)
First name

Last name

Suffix

Middle name

IDENTIFICATION INFORMATION
Section 2 - Social Security Number
Social Security Number

SUPPLEMENTAL QUESTIONS
Section 3 - Your Use of Illegal Drugs and Drug Activity
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.
(a) Since the age of 16 or in the last 5 years, whichever is shorter, have you illegally used any controlled substance, for example,
marijuana, cocaine, crack cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), amphetamines, depressants
(barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), or prescription drugs?

YES

NO

(b) Have you ever illegally used a controlled substance while employed as a law enforcement officer, prosecutor, or courtroom
official; while possessing a security clearance; or while in a position directly and immediately affecting the public safety?

YES

NO

If you answered "Yes" to any question above, provide the date(s), identify the controlled substance(s) and/or prescription drugs used, and the number
of times each was used.
Month/Year

Month/Year

Controlled Substance/Prescription Drug Used

Number of Times Used

To

To

Section 4 - Your Use of Alcohol
In the last 5 years, has your use of alcoholic beverages (such as liquor, beer, wine) resulted in any alcohol-related treatment or
counseling (such as for alcohol abuse or alcoholism)?

YES

NO

If you answered "Yes", provide the dates of treatment and the name and address of the counselor below.
Month/Year

Month/Year
To

To

Page 1

Name/Address of the Counselor or Doctor

State

Zip Code

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5 - Psychological and Emotional Health
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. Every day individuals with mental health conditions carry out their duties without presenting a
security risk. While most individuals with mental health conditions do not present security risks, there may be times when such a condition can affect a
person’s eligibility for a security clearance.
Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce, major injury, service in a military combat
environment, sexual assault, domestic violence, or other difficult work-related, family, personal, or medical issues may lead to grief, depression, or other
responses. The government recognizes that mental health counseling and treatment may provide important support for those who have experienced such
events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage those who might benefit from such
treatment from seeking it.
Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a
sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled
facilities or information systems. Seeking or receiving mental health care for personal wellness and recovery may contribute favorably to decisions about your
eligibility.
5A

Has a court or administrative agency EVER issued an order declaring you mentally incompetent?

YES

NO (If NO, proceed to Section 5B)

Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Entry #1
Provide the date this occurred. (Month/Year)

Provide the name of the court or administrative agency that declared you mentally incompetent.

Est.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Was this matter appealed to a higher court or administrative agency?
YES

NO

Appeal #1
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Appeal #2
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street

Page 2

City

State

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5A - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Entry #2
Provide the date this occurred. (Month/Year)

Provide the name of the court or administrative agency that declared you mentally incompetent.

Est.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Was this matter appealed to a higher court or administrative agency?
YES

NO

Appeal #1
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Appeal #2
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street

Page 3

City

State

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5A - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Entry #3
Provide the date this occurred. (Month/Year)

Provide the name of the court or administrative agency that declared you mentally incompetent.

Est.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Was this matter appealed to a higher court or administrative agency?
YES

NO

Appeal #1
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Appeal #2
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street

Page 4

City

State

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5B - Psychological and Emotional Health - (Continued)
5B

Has a court or administrative agency EVER ordered you to consult with a mental health
professional (for example, a psychiatrist, psychologist, licensed clinical social worker, etc.)?
(An order to a military member by a superior officer is not within the scope of this question,
and therefore would not require an affirmative response. An order by a military court would be
within the scope of the question and would require an affirmative response.)

YES

NO (If NO, proceed to Section 5C)

Complete the following if you answered 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.
Entry #1
Provide the date this occurred. (Month/Year)

Provide the name of the court or administrative agency that ordered you to consult with a mental health
professional.

Est.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Was this matter appealed to a higher court or administrative agency?
YES

NO

Appeal #1
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Appeal #2
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street

Page 5

City

State

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5B - Psychological and Emotional Health - (Continued)
Complete the following if you answered 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.
Entry #2
Provide the date this occurred. (Month/Year)

Provide the name of the court or administrative agency that ordered you to consult with a mental health
professional.

Est.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide the final disposition.

Was this matter appealed to a higher court or administrative agency?
YES

NO

Appeal #1
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Appeal #2
Provide the name of the court or administrative agency.

Provide the final disposition.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street

Page 6

City

State

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5C - Psychological and Emotional Health - (Continued)
5C Have you EVER been hospitalized for a mental health condition?

YES

NO (If NO, proceed to Section 5D)

Complete the following if you answered 'Yes' to having EVER been hospitalized for a mental health condition.
Entry #1
Was the admission voluntary or involuntary?
Voluntary

Explanation

Provide the dates of treatment.
To Date

From Date

(Month/Year)

(Month/Year)

Est.

Involuntary Explanation

Est.
Present

Provide the name of the facility where treatment was provided.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Entry #2
Was the admission voluntary or involuntary?
Voluntary

Explanation

Provide the dates of treatment.
To Date

From Date

(Month/Year)

Involuntary Explanation

(Month/Year)

Est.

Est.
Present

Provide the name of the facility where treatment was provided.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code

Page 7

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5C - Psychological and Emotional Health - (Continued)
Complete the following if you answered 'Yes' to having EVER been hospitalized for a mental health condition.
Entry #3
Was the admission voluntary or involuntary?
Voluntary

Explanation

Provide the dates of treatment.
To Date

From Date

(Month/Year)

(Month/Year)

Est.

Involuntary Explanation

Est.
Present

Provide the name of the facility where treatment was provided.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Entry #4
Was the admission voluntary or involuntary?
Voluntary

Explanation

Provide the dates of treatment.
To Date

From Date

(Month/Year)

Involuntary Explanation

(Month/Year)

Est.

Est.
Present

Provide the name of the facility where treatment was provided.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code

Page 8

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5D - Psychological and Emotional Health - (Continued)
The following question asks whether you have been diagnosed with a specified mental health condition that may, particularly if untreated, impact your
judgment, reliability, or trustworthiness. If you answer in the affirmative, we will seek additional information about the seriousness and symptoms of the
condition, as well as any applicable course of treatment. It is important to note that any such diagnosis, in and of itself, is not a reason to revoke or deny
eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or
eligibility for physical or logical access to federally controlled facilities or information systems.

5D Have you EVER been diagnosed by a physician or other health professional (for example, a
psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic
disorder, schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder,
borderline personality disorder, or antisocial personality disorder?

YES

NO (If NO, proceed to Section 5E)

Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.
Entry #1
Identify the diagnosis or health condition.

Provide the dates of diagnosis.
To Date

From Date

(Month/Year)

(Month/Year)

Est.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.

Est.
Present

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Same as above

Provide the telephone number of the agency/organization/facility.
Same as Above
Telephone number

Day
Extension

Provide the address of agency/organization/facility where counseling/treatment was provided.
City

Was the counseling/treatment effective in managing your symptoms?
YES

Page 9

NO

Explanation

State

International or DSN phone
number
Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

Night

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5D - Psychological and Emotional Health - (Continued)
Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.
Entry #2
Identify the diagnosis or health condition.

Provide the dates of diagnosis.
To Date

From Date

(Month/Year)

(Month/Year)

Est.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.

Est.
Present

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Same as above

Provide the telephone number of the agency/organization/facility.
Same as above
Telephone number

Day
Extension

Provide the address of agency/organization/facility where counseling/treatment was provided.
City

Was the counseling/treatment effective in managing your symptoms?
YES

Page 10

NO

Explanation

State

International or DSN phone
number
Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

Night

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5D - Psychological and Emotional Health - (Continued)
Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.
Entry #3
Identify the diagnosis or health condition.

Provide the dates of diagnosis.
To Date

From Date

(Month/Year)

(Month/Year)

Est.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.

Est.
Present

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Same as above

Provide the telephone number of the agency/organization/facility.
Same as above
Telephone number

Day
Extension

Provide the address of agency/organization/facility where counseling/treatment was provided.
City

Was the counseling/treatment effective in managing your symptoms?
YES

Page 11

NO

Explanation

State

International or DSN phone
number
Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

Night

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5D - Psychological and Emotional Health - (Continued)
Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.
Entry #4
Identify the diagnosis or health condition.

Provide the dates of diagnosis.
To Date

From Date

(Month/Year)

(Month/Year)

Est.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.

Est.
Present

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Same as above

Provide the telephone number of the agency/organization/facility.
Same as above
Telephone number

Day
Extension

Provide the address of agency/organization/facility where counseling/treatment was provided.
City

Was the counseling/treatment effective in managing your symptoms?
YES

Page 12

NO

Explanation

State

International or DSN phone
number
Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

Night

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5D - Psychological and Emotional Health - (Continued)
In the last seven years, have there been any occasions when you did not consult with a medical
professional before altering or discontinuing, or failing to start a prescribed course of treatment for any of
the listed diagnoses?

YES

NO (If NO, proceed to Section 5E)

5D.1 Are you currently in treatment?

YES

NO (If NO, proceed to Section 5E)

Complete the following if you answered 'Yes' to currently being in treatment.
Entry #1
Provide the name of the health care professional providing such
treatment.

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street

City

State

Zip Code

Country

Entry #2
Provide the name of the health care professional providing such
treatment.

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street

City

State

Zip Code

Country

Entry #3
Provide the name of the health care professional providing such
treatment.

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

Night

International or DSN phone
number

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street

City

State

Zip Code

Country

Entry #4
Provide the name of the health care professional providing such
treatment.

Provide the telephone number of the health care professional.
Day
Telephone number

Extension

International or DSN phone
number

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street

Page 13

City

State

Zip Code

Country

Night

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5E - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'No' to 5A, 5B, 5C, and 5D (All). If 'Yes' was selected for either 5A, 5B, 5C, or 5D, (any of them), proceed to
Certification.
5E Do you have a mental health or other health condition that substantially adversely affects your
YES
NO (If NO, proceed to Certification)
judgment, reliability, or trustworthiness even if you are not experiencing such symptoms today?
(Note: If your judgment, reliability, or trustworthiness is not substantially adversely affected by a mental health or other condition, then you should answer
"no" even if you have a mental health or other condition requiring treatment. For example, if you are in need of emotional or mental health counseling as a
result of service as a first responder, service in a military combat environment, having been sexually assaulted or a victim of domestic violence, or marital
issues, but your judgment, reliability or trustworthiness is not substantially adversely affected, then answer "no.")
Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.
Did you ever receive or are you currently receiving counseling or treatment for that condition? (You may choose not to answer this question. However,
such consultation or treatment will not disqualify you and is considered to be a positive action.)
YES

I decline to answer (If I decline to answer, proceed to Certification)

NO Explanation
Entry #1
If you responded 'Yes' to having ever received or you are currently receiving counseling or treatment for that condition.
#1 Provide the dates of counseling or treatment
To Date (Month/Year)

From Date (Month/Year)

Est.

Provide the telephone number of the health care professional.
Day
Night
Telephone number

Extension

Present

Est.

International or DSN phone
number

Provide the name of the health care professional.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Provide the telephone number of the agency/organization/facility.
Same as above

Same as Above
Telephone number

Day
Extension

International or DSN phone
number

Provide the address of agency/organization/facility where counseling/treatment was provided.

Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

Street

State

#2 Provide the dates of counseling or treatment

Country

Zip Code

Provide the telephone number of the health care professional.

To Date (Month/Year)

From Date (Month/Year)

Night

Est.

Est.

Telephone number

Extension

Present

Day

Night

International or DSN phone
number

Provide the name of the health care professional.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Provide the telephone number of the agency/organization/facility.
Same as Above

Same as above

Telephone number

Day
Extension

Provide the address of agency/organization/facility where counseling/treatment was provided.
City

State

Have you ever chosen not to follow a prescribed course of treatment for any of these conditions?
YES If YES provide explanation
NO

Page 14

International or DSN phone
number
Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

Night

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Section 5E - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.
Entry #2
If you responded 'Yes' to having ever received or you are currently receiving counseling or treatment for that condition.
#1 Provide the dates of counseling or treatment
From Date (Month/Year)

To Date (Month/Year)

Est.

Provide the telephone number of the health care professional.
Day
Night
Telephone number

Extension

Present

Est.

International or DSN phone
number

Provide the name of the health care professional.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Same as above

Provide the telephone number of the agency/organization/facility.
Same as Above
Telephone number

Day
Extension

International or DSN phone
number

Provide the address of agency/organization/facility where counseling/treatment was provided.

Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

Street

State

#2 Provide the dates of counseling or treatment
To Date (Month/Year)

From Date (Month/Year)

Est.

Country

Zip Code

Provide the telephone number of the health care professional.
Day
Night
Telephone number

Extension

Present

Est.

Night

International or DSN phone
number

Provide the name of the health care professional.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code

Provide the name of any agency/organization/facility
where counseling/treatment was provided.

Same as above

Provide the telephone number of the agency/organization/facility.
Same as Above
Telephone number

Day
Extension

Provide the address of agency/organization/facility where counseling/treatment was provided.
City

State

Have you ever chosen not to follow a prescribed course of treatment for any of these conditions?
YES If YES provide explanation
NO

Page 15

International or DSN phone
number
Same as above

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

Night

Zip Code

Country

Standard Form 85P-S
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

SUPPLEMENTAL QUESTIONNAIRE
FOR SELECTED POSITIONS

Form approved:
OMB No. 3206 0258

CERTIFICATION

Certification That My Answers Are True
My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made
in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See
section 1001 of title 18, United States Code).
Signature (Sign in ink)

Page 16

Date