DOE F 206.5 Privacy Act Information Request

DOE F 206.5
(06/2021)
All other editions are obsolete

U.S. DEPARTMENT OF ENERGY
PRIVACY ACT INFORMATION REQUEST

OMB Control No.
Exp. Date

CONSENT FOR DISCLOSURE OF RECORDS UNDER THE PRIVACY ACT
To provide consent and authorize the agency to disclose your records to another person or entity, please provide the
information below. (This form may also be used if you are the parent consenting to and authorizing disclosure of the
records of a minor or the legal guardian consenting to and authorizing disclosure of the records of an incompetent. Please
complete the appropriate Items in Part I, II, III 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 identifications 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 or emailed password protected unless the
requester states a preference for paper copies. Part IV is For Agency Use Only. FALSE STATEMENTS SUBJECT TO
CRIMINAL PENALTIES. SEE REVERSE SIDE.
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.
PART I – INFORMATION USED FOR IDENTITY-PROOFING AND AUTHENTICATION
(This information is required for the agency to verify your identity)
1. Full Name (First, Middle, Last)

2. Date of Request

If Applicable: Information for Request by Parent or Legal Guardian
3. Full Name of Individual Whose Record(s) Are Requested (First, Middle, Last)

4. Documents Required to Establish Relationship/Guardianship
(Check all that apply)

☐ Court Order establishing guardianship
☐ Birth Certification
5. To Verify My Identity

☐ I have completed and signed this form with a physical or digital signature
☐ 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 General
Release form/letter indicating the individual has given permission to release the records to the Authorized Representative, an Authorization
for Representative form/letter giving them permission to act on their behalf, copies of 2 forms of ID from the individual whose record(s) are
requested), and 2 forms of ID from the authorized representative.
DOE F 206.5
(06/2021)

508 Compliant

DOE F 206.5
(06/2021)
All other editions are obsolete

OMB Control No.
Exp. Date

PART II – ADDITIONAL INFORMATION REQUIRED TO LOCATE THE RECORD(S)
(This information is required for the agency to be able to match the individual’s information provided in this request with the records that pertain to that individual)
6. Social Security Number

I

I

I

I– I

I

I– I

7. Date of Birth (MM/DD/YYYY)

I

I

I

I

8. Program Office, Staff Office, Field Office, or Lab That You Are Requesting Records From

08/11/2021
9. Date Range of Records Requested

TO
10. 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.):

11. Description of Requested Records

☐
☐
☐
☐
☐

Administrative Review Files
Grievance Files
Medical
Occupation and Industrial Records
Payroll/Leave Records

☐
☐
☐
☐
☐

☐ Other (Type of Records Requested)

Personnel Records – j
Personnel Security Clearance Files
Radiation Exposure Report
Training Records
X-Ray Reports

_________________________________

PART III – RECIPIENT INFORMATION
13. Recipient’s Relationship to the individual who is the subject of the
records

12. Name of Recipient (Person or Entity) to Whom Disclosure is Authorized
(First, Middle, Last)

☐
☐
☐
☐

14. Recipient’s Mailing Address

Parent or a Minor
Legal guardian
Third-party representative authorized by the individual
Member of Congress:

_______________________________
(Name and State)

15. Requestor’s Contact Information

Telephone No. (Include Area Code): ________________________ Email Address: _______________________________________
16. Declaration
I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above and requesting
access to my records [, or records that I am entitled to request as the parent of a minor or the legal guardian of an incompetent], and I understand that any falsification of this
statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of not more than five years, or both, and that requesting or obtaining any record(s) under
false pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.
17. Requester’s Digital Signature

18. Date

PART IV – FOR AGENCY USE ONLY
19. Proof of Identity Witnessed in Person (Name, Title, Location)

20. Case Number

21. Form of Identify
☐ Driver’s License (Date Received) _____________________
☐ Passport
(Date Received) _____________________
☐ Other

22. Action Assigned To/Date

23. Additional Identifying Information:

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.
DOE F 206.5
(06/2021)

2

508 Compliant

DOE F 206.5
(06/2021)
All other editions are obsolete

OMB Control No.
Exp. Date

(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 Privacy Act Office, United States Department of Energy, 19901 Germantown Road, Room G302, Germantown, Maryland 20874; or
(2) By Fax: 301-903-7738 Attn: Privacy Act Request.
(3) By email as a password protected document: [email protected]
(4) 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:
htpp:// energy.gov/privacy.
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 or email, 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.
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 statement to a Government agency and under subsection (i)(3) of the Act for obtaining records under false
pretenses.

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 The Privacy Act Office, United States Department of Energy, 19901
Germantown Road, Room G-302, Germantown, Maryland 20874; and to the Office of Management and Budget (OMB),
Paperwork Reduction Project (1910-1700), Washington, DC 20503. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
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.
DOE F 206.5
(06/2021)

3

508 Compliant