DOE F 470.5 Authorization and Consent to Release Human Reliability P

DOE F 470.5 (06/2023)

PREVIOUS EDITIONS ARE OBSOLETE

U.S. DEPARTMENT OF ENERGY

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

OMB Control No. 1910-5122
Expiration Date:

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. This statement is in reference to the relevant System of Records Notice (SORN) per Circular A-108, DOE-50,

HRP Records SORN 230104 (https://www.federalregister.gov/documents/2009/01/09/E8-31316/privacy-act-of-1974publication-of-compilation-of-privacy-act-systems-of-records).

OMB BURDEN DISCLOSURE STATEMENT
This data is being collected as authorization and consent to release HRP records. The data you supply will be
used to ensure that individuals who occupy positions affording access to certain materials, nuclear explosive
devices, facilities, and programs meet the highest standards of reliability and physical and mental suitability.
Public reporting burden for this collection of information is estimated to average 2 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
Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22,
Information Collection Management Program (1910-5122), U.S. Department of Energy, 1000 Independence
Ave., SW, Washington, DC 20585; and to the Office of Management and Budget (OMB), OIRA, Paperwork
Reduction Project (1910-5122), Washington, DC 20503. Notwithstanding any other provision of the law, no
person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection
of information subject to the requirements of the Paperwork Reduction Act unless that collection of information
displays a currently valid OMB control number. Submission of this data is mandatory.
SECTION I. CONSENT
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 a 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 preemployment check performed by either
(DOE
contractor’s corporate name, 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.

DOE F 470.5 (06/2023)

Section 508 Compliant

OMB Control No. 1910-5122
Expiration Date:

DOE F 470.5 (06/2023)

PREVIOUS EDITIONS ARE OBSOLETE

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.
8. SECTION II. PARTICIPANT SIGNATURE
9. Name:
10. Signature:
11. Date:

12. SECTION III. HRP MANAGEMENT OFFICIAL APPROVAL
13. Name:
14. Signature:

DOE F 470.5 (06/2023)

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15. Date:

Section 508 Compliant