Supplemental Questionnaire For Selected Positions {SF 85P-S}

Standard Form 85P-S (EG) Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206-0191 NSN 7540-01-368-7778 85-1700 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: you must type or legibly print your answers in black ink, use State codes, etc. Be sure to sign and date the certification statement at the bottom of this page. 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. IDENTIFICATION INFORMATION 1 FULL NAME Last Name Enter your name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions. First Name Middle Name 2 Jr., II, etc. SOCIAL SECURITY NUMBER SUPPLEMENTAL QUESTIONS 3 YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you, but neither your truthful response nor information derived from your response will be used as evidence against you in any subsequent criminal proceeding. Yes No a Since the age of 16 or in the last 7 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? 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? b 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 To Controlled Substance/Prescription Drug Used Number of Times Used To 4 YOUR USE OF ALCOHOL In the last 7 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)? If you answered "Yes," provide the dates of treatment and the name and address of the counselor below. Do not repeat information reported in Month/Year Month/Year To Name/Address of Counselor or Doctor State Yes No ZIP Code To 5 YOUR MEDICAL RECORD In the last 7 years, have you consulted with a mental health professional (psychiatrist, psychologist, counselor, etc.) or have you consulted with another health care provider about a mental health related condition? You do not have to answer "Yes" if you were only involved in marital, grief, or family counseling not related to violence by you. If you answered "Yes," provide the dates of treatment and the name and address of the therapist or doctor below. Month/Year To Month/Year Name/Address of Therapist or Doctor State Yes No ZIP Code To 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) Date Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995. Designed using Perform Pro, WHS/DIOR, Sep 95 American LegalNet, Inc. www.FormsWorkFlow.com