OPM 5096 Part D - Public Trust-Specific (Select Positions)

For Reference Only

Part D - Public Trust-Specific (Select Positions)

Psychological and Emotional Health

The U.S. government recognizes the importance of the psychological and emotional health of its workforce and advocates proactive involvement with mental health and related services to support wellbeing and recovery of federal employees and others.

The following questions ask about behavioral and mental health experiences.

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 for fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems. Seeking, undergoing, or continuing behavioral or mental health care is associated with good judgment.

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

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent

What is the name of the court or administrative agency declaring you mentally incompetent?

[ Text ]

When did this court or administrative agency declare you mentally incompetent?	[ mm/dd/yy ]		[] Estimated
Is this court or administrative agency in the U.S.?				[] Yes		[] No

[2] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent and in the U.S.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent but not in the U.S.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent. Follow-up Appeal Question.

Did you appeal this decision to a higher court or administrative agency?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent and Affirmative Appeal.

What is the name of the court or administrative agency you appealed to?

[ Text ]

Is this appeal's court or administrative agency in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent, Appeal, and in the U.S.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)	[ Text ]
City		[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent, Appeal, but not in the U.S.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent and Appealed. Appeal Outcome Question.

What was the final disposition? (that is, did the order declaring you mentally incompetent stand or did you successfully overturn it)

[ Text ]

Is there another appeal to report?

[] Yes

[] No

[1] ] Branch Auto Populate for Affirmative Answer on Declared Mentally Incompetent. Another Instance Question.

Do you have another instance in which a court or administrative agency issued an order declaring you mentally incompetent to report?

[] Yes

[] No

*** End Of Branch ***

The U.S. government recognizes the importance of the psychological and emotional health of its workforce and advocates proactive involvement with mental health and related services to support wellbeing and recovery of federal employees and others.

In the past five years, has a court or administrative agency 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

[1] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional.

What is the name of the court or administrative agency ordering you to consult with a mental health professional?

[ Text ]

When did this court or administrative agency order you to consult with a mental health professional?

[ mm/dd/yy ]

[] Estimated

Is this court or administrative agency in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional in the U.S.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional but not in the U.S.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional. Appeal Questions.

What was the final disposition?

[ Text ]

Did you appeal this decision to a higher court or administrative agency?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional and Affirmative Appeal.

What is the name of the court or administrative agency you appealed to?

[ Text ]

Is this appeal's court or administrative agency in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional, Appealed, and in the U.S.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional, Appealed, but not in the U.S.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer on Order to Consult a Mental Health Professional and Affirmative Appeal. Appeal Outcome Question.

What was the final disposition? (that is, did the order to consult with a mental health professional stand or did you successfully overturn it)

[ Text ]

Is there another appeal to report

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Consult a Mental Health Professional. Another Instance Question.

Do you have another instance in which a court or administrative agency issued an order to consult a mental health professional stand to report?

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you been admitted to a hospital, or been required to be evaluated in a hospital for any mental health condition or behavioral emergency (include any inpatient hospitalizations, partial hospitalizations, and emergency room visits)?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Hospitalization.

Was the hospitalization voluntary? (A No response will be considered as involuntary)

[] Yes

[] No

When did you go to the hospital?

[ mm/yy ]

[] Estimated

When did leave the hospital?

[ mm/yy ]

[] Estimated

What was the name of the facility?

[ Text ]

Is this facility in the U.S.?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Hospitalization in the U.S.

What is the address of the facility?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Hospitalization but not in the U.S.

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Hospitalization. Another Instance Question.

Do you, in the last five years, have another occurrence of having been admitted to a hospital, or been required to be evaluated in a hospital for ANY mental health condition or behavioral emergency (include any inpatient hospitalizations, partial hospitalizations, and emergency room visits)?

[] Yes

[] No

*** End Of Branch ***

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
		[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer to Diagnosed.

What are the dates of diagnosis?

From (Month/Year)

[ mm/yy ]

[] Estimated

To (Month Year)

[ mm/yy ]

[] Estimated

[] Present

What is the name of the health care professional who diagnosed you, or is currently treating you for such a diagnosis, or with whom you have discussed such condition?

[ Text ]

What is the health care professional's telephone number?

[Ctry|Num|Ext]

Type [] [Day/Night/Both]

Is the address of the healthcare professional, in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Diagnosed and in the U.S.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Diagnosed but not in the U.S.

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Diagnosed and in the U.S. Other Agency, Organization, Facility Question.

Is the agency, organization, or facility where counseling/treatment was provided same as above?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Diagnosed and in the U.S. Agency, Organization, Facility Details Question.

What is the agency, organization, or facility where counseling/treatment was provided?

[ Text ]

What is the agency, organization, or facility's telephone number?

[Ctry|Num|Ext]

Type [] [Day/Night/Both]

Is the address of the agency, organization, or facility where treatment was provided in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Diagnosed. Affirmative to Agency, Organization, Facility Details. Address Question.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Diagnosed. Negative to Agency, Organization, Facility Details. Address Question.

What is the address?

City

[ Text ]

Country

[ DROPDOWN ]

[1] Branch Diagnosis Questions.

Have you ever believed you had any of the following?

A. Psychotic symptoms or psychosis (i.e., hearing, seeing, feeling, or smelling things that were not real or could not be perceived by others; belief that other people are out to get you, that you are being followed, watched, or recorded; belief that you could read other people's minds or they can read yours; or belief that you have a special power).

[] Yes

[] No

B. Manic or hypomanic episodes (i.e., sustained periods of very high energy, feeling hyper, euphoric, highly distractible, or having a decreased need for sleep or not sleeping for long periods of time without feeling tired).

[] Yes

[] No

C. Impulsive behavior or behavior you felt unable to control and caused negative consequences (e.g., uncontrolled gambling, other addictive behavior, compulsive sexual behavior etc.).

[] Yes

[] No

D. A plan to hurt or kill someone else that you either acted upon or would have acted upon if someone had not intervened.

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Diagnosed. Treatment Question.

Did you seek treatment due to any of these?		[] Yes	[] No

[3] Branch Auto Populate for Affirmative Answer to Diagnosed. Treatment Details Questions.

What are the treatment dates?

From (Month/Year)

[ mm/yy]

[] Estimated

To (Month Year)

[ mm/yy]

[] Estimated

[] Present

What is the name of the health care professional who treated you, or is currently treating you?

[ Text ]

What is the health care professional's telephone number?

[Ctry|Num|Ext]

Type [] [Day/Night/Both]

Is the address of the healthcare professional in the U.S.?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer to Diagnosed. Treatment Address Questions if Provider in the U.S.

What is the address?

Street (include Apartment, Unit, or Suite Number, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[4] Branch Auto Populate for Affirmative Answer to Diagnosed. Treatment Address Questions if Provider is not in the U.S.

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer to Diagnosed. Another Instance Question.

Do you have any additional episodes described in A, B, C, or D to report?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Diagnosed and in the U.S. Another Instance Question.

Do you have another instance of having 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

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