Instructions for Completing this Form
1.Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form. You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.
2.All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise noted.
3.Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country drop down feature.
4.When entering a U.S. address or location, select the state or territory from the "States" drop down list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" drop down list and leave the "State" field blank.
5.The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.
6.For telephone numbers in the U.S., ensure that the area code is included.
7.All dates provided in this form must be in Month/Day/ Year or Month/Year
format. Use numbers (01-12) to indicate months. For example, July 29,1968, should be written as 07/29/1968. If you are unable to report an exact date, approximate or estimate the date to the best of your ability,and indicate this by checking the “Estimate” box.
Final Determination on Your Suitability
Final determination on your suitability for a public trust position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, or sexual orientation when making determinations of suitability for a public trust position.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to five (5) years imprisonment. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you provide on this form and to make your comments part of the record.
Disclosure Information
The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. The office that gave you this form will provide you a copy of its routine uses.
Office of Personnel Management (OPM) Routine Uses
The Privacy Act routine uses of agencies conducting or requesting investigations, or with authorized custody over your investigative information, commonly include some or all of the following:
a.To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government or the Government of the District of Columbia having a need to investigate, evaluate, or make a determination regarding loyalty to the United States; qualifications, suitability, or fitness for Government employment or military service; eligibility for logical or physical access to federally-controlled facilities or information systems;eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.
b.To an element of the U.S. Intelligence Community as identified in E.O.12333, as amended, for use in intelligence activities for the purpose of protecting United States national security interests.
c.To any source from which information is requested in the course of an investigation, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested.
d.To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.
e.To an agency, office, or other establishment in the executive, legislative,or judicial branches of the Federal Government in response to its request,in connection with its current employee’s, contractor employee’s, or military member’s retention; loyalty; qualifications, suitability, or fitness for employment; eligibility for logical or physical access to federally-controlled facilities or information systems; eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.
f.To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual. However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from the subject of the investigation.
g.To disclose information to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government.
h.For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative support.
i.To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.
j.To appropriate agencies, entities, and persons when (1) OPM suspects or has confirmed that there has been a breach of the system of records; (2) OPM has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, the agency (including its information systems, programs and operations), the Federal Government,or national security; and (3) the disclosure made to such agencies,entities, and persons is reasonably necessary to assist in connection with OPM’s efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm.