3206-NEW PVQ Certification and Releases

Personnel Vetting Questionnaire Revised [date TBD] U.S. Office of Personnel Management 5 CFR Parts 731, 736, and 1400

PERSONNEL VETTING QUESTIONNAIRE UNITED STATES OF AMERICA

Form Approved OMB No.####-### [TBD]

Certification

My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I further affirm, to the best of my knowledge, I have not included any classified information in completing this questionnaire. I have carefully read the instructions to complete this form. I understand that a knowing and willful false statement on this form is punishable by fine or imprisonment or both. See 18 U.S.C. § 1001. I understand that intentional withholding, misrepresenting, falsifying, or including classified information may have a negative effect on my security clearance, employment prospects, or job status, up to and including denial or revocation of my security clearance, or my removal or debarment from Federal service, as applicable.

Signature

Date Signed

PERSONNEL VETTING QUESTIONNAIRE

AUTHORIZATION FOR RELEASE OF INFORMATION

By signing and dating this document you are authorizing the entities listed to release information about you for the purposes stated.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my personnel vetting investigation, to include ongoing evaluation and continuous vetting, to obtain any information relating to my activities, conduct, integrity, judgment, loyalty, and reliability from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of information. This information may include, but is not limited to current and historic academic, residential, achievement, performance, attendance, disciplinary, employment, criminal, financial, credit, and publicly available electronic information. I authorize the federal agency conducting my personnel vetting investigation, to include ongoing evaluation and continuous vetting, to disclose the record of my investigative results to the requesting agency, or as otherwise authorized in accordance with the Privacy Act, for the purpose of making a personnel vetting trust determination regarding my suitability or fitness for initial and ongoing employment working for or on behalf of the Federal government, appointment to or retention in a national security position, eligibility and continued eligibility for access to classified information, or initial and ongoing eligibility to be issued a federal Personal Identity Verification (PIV) credential permitting access to federal facilities or information systems.

I Understand that, for these purposes, publicly available electronic information includes any electronic information that has been published or broadcast for public consumption, is available on request to the public, is accessible online to the public, is available to the public by subscription or purchase, or is otherwise lawfully accessible to the public. I further understand that this authorization does not require me to provide passwords, log into a private account, or take any action that would disclose non-publicly available electronic information.

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to the investigative service provider of the Federal department/agency conducting my personnel vetting investigation for the purposes outlined above. I authorize SSA to provide explanatory information to said department/agency in the event of a discrepancy.

I Understand that, for financial or lending institutions, tax agencies, medical institutions, hospitals, health care professionals, and other sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.

I Authorize any investigator, special agent, or other duly accredited representative of the Office of Personnel Management, the Federal Bureau of Investigation, the Department of Defense, the Department of Homeland Security, the Office of the Director of National Intelligence, Department of State, or any other authorized federal agency, to request criminal record information on me from criminal justice agencies for the purpose of determining my suitability, fitness, or eligibility for appointment to, or retention in a non-sensitive position or a national security position, my eligibility for access to classified information, or my eligibility for a federal Personal Identity Verification (PIV) credential permitting access to federal facilities of information systems, in accordance with 5 U.S.C. § 9101.

I Understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes provided in this personnel vetting questionnaire and that it may be disclosed by the Federal Government only as authorized by law.

I Authorize the information to be used to conduct officially sanctioned and approved personnel vetting-related studies and analyses, which will be maintained in accordance with the Privacy Act.

Copies of this authorization with my handwritten, electronic, or digital signature are valid. This authorization is in effect as long as I am under consideration to occupy a position affiliated with the Federal Government that requires vetting or until termination of my affiliation with the Federal Government, whichever is sooner, as applicable.

Signature	Full Name	Date Signed (mm/dd/yyyy)
Other Names Used	Date of Birth (mm/dd/yyyy)	Social Security Number
Current Street Address, Apt. # (no P.O. Box Address)	City (or Country)	State	ZIP Code	Telephone Number

PERSONNEL VETTING QUESTIONNAIRE

FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION

Disclosure

One or more credit reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.

Purpose

Credit information from one or more consumer reporting agencies may be collected as part of your personnel vetting investigation to include ongoing evaluation and continuous vetting. The Federal Government considers this information when determining your eligibility to occupy a public trust position, national security position, or to access classified information, as applicable. For non-sensitive positions and physical or logical access, the need for a consumer or credit report is dependent on circumstances in your background. Any credit information obtained is disclosable by law to federal agencies needing it for the purposes stated. The Federal Government will not use information from your consumer or credit report in violation of federal or state equal employment opportunity laws or regulations.

Authorization

I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized federal agency conducting my personnel vetting investigation to request, and any consumer reporting agency to provide, credit reports for the purposes described above.

Copies of this authorization with my handwritten, electronic, or digital signature are valid. This authorization is in effect as long as I am under consideration to occupy a position affiliated with the Federal Government that requires vetting or until termination of my affiliation with the Federal Government, whichever is sooner, as applicable.

Full Name	Social Security Number
Signature	Date Signed (mm/dd/yyyy)

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT

TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

If you answered "Yes" to questions in the Psychological and Emotional Health Sections of the Federal Personnel Vetting Questionnaire, carefully read this authorization to release information about you, then sign below.

This is an authorization for the investigator to ask your health practitioner(s) the questions below concerning your mental health consultations. 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. The government recognizes that mental health counseling and treatment may provide important support for those who have experienced traumatic events, as well as for those with other mental health conditions.

While most individuals with mental health conditions do not present security risks, there may be times when such a condition can affect suitability or fitness for positions of public trust, eligibility to occupy a national security sensitive position, or eligibility to access classified information. Seeking or receiving mental health care for personal wellness and recovery may contribute favorably to decisions about your eligibility. Your signature will allow the practitioner(s) to answer only those questions identified below.

Authorization

I am seeking assignment to or retention in a public trust and/or national security sensitive position. As part of the investigative process, I hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my personnel vetting investigation, to include ongoing evaluation and continuous vetting, to request, and my health practitioner(s) to provide, the information requested below, relating to my mental health consultations.

In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to my health care provider/entity. Revocation of this authorization is not effective until received by my health care provider/entity. I understand that I may revoke this authorization, except to the extent that action has already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I understand the information disclosed pursuant to this authorization for use by the Federal Government only for purposes provided in the Personnel Vetting Questionnaire will no longer be covered by the HIPAA Privacy Rule, and that the Federal Government may redisclose the information as authorized by law, subject to Privacy Act safeguards.

Copies of this authorization with my handwritten, electronic, or digital signature are valid. This authorization is in effect as long as I am under consideration to occupy a position affiliated with the Federal Government that requires vetting or until termination of my affiliation with the Federal Government, whichever is sooner, as applicable.

Signature		Full name			Date signed (mm/dd/yyyy)
Other names used					Social Security Number
Current street address, Apt. #	City (Country)		State	ZIP Code	Telephone number

For Use by Practitioner(s) Only

Does the individual under investigation have a condition that could impair the individual’s judgment, reliability, or trustworthiness? YES NO If so, describe the nature of the condition and the extent and duration of the impairment or treatment. What is the prognosis? Dates of treatment?
Signature (Sign in ink)	Practitioner name	Date signed (mm/dd/yyyy)

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