FD-1065.pdf
PDF 3 MB Posted
- Attached to
- RFP - Medical Evaluations and Services Federal contract opportunity
- Solicitation number
- 15F06725R0000538
About this file
The document is an FBI Form FD-1065 Report of Medical History, dated 07/16/2025. The two-page form is designed for medical documentation and screening purposes, requiring an individual to provide comprehensive medical information. Key sections include reporting current medications, allergies, past/current medical history, and potential medical conditions that could impact job performance. The form includes specific instructions for completion, with checkboxes for various medical history items and space for detailed explanations. There is a Privacy Act Statement noting that information collection is voluntary but necessary for medical care and employment eligibility determination. A GINA (Genetic Information Nondiscrimination Act) notice explicitly instructs the individual not to provide genetic information when completing the form.
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Text version
FD-1065
07/16/2025
FEDERAL BUREAU OF INVESTIGATION
REPORT OF MEDICAL HISTORY
DATE COMPLETED
NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons
1. Examinee Legal Name (Last, First, Middle) 2. Date of Birth
3. Division/Field Office 4. Examining Facility
5. Current Medications, Dose, and Frequency (List all medications to include over the counter and herbals)
NONE (check box)
6. Allergies (include insect bites/stings and common foods)
NONE (check box)
PAST/CURRENT MEDICAL HISTORY – Check Each Item; if “YES” Explain in the below space. List explanation by condition item.
Item Yes No
7. Do you have any medical condition or physical impairment that could interfere with or otherwise limit your ability in any way to perform your duties fully?
8. Have you ever been admitted or observed overnight in a hospital?
9. Have you had or been advised to have any type of surgery/operation?
10. Have you applied for or are you receiving a pension or compensation for any type of disability?
11. Do you currently have or have you previously had a medical condition that has been evaluated or treated by a clinic, physician, healer, or other practitioner?
12. If you are currently an FBI employee, in the previous two years, have you consulted with or been treated by a clinic, physician, healer, or other practitioner for anything other than minor illness?
Explanation of all “Yes” findings by Examinee
13. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purpose of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment.
14a. Examinee Legal Name 14b. Examinee Signature 14c. Date Signed
Note: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE “TO BE OPENED BY MEDICAL PERSONNEL
ONLY”
FD-1065 - 1 -
FD-1065
07/16/2025
FEDERAL BUREAU OF INVESTIGATION
REPORT OF MEDICAL HISTORY
DATE COMPLETED
15. SUMMARY AND ELABORATION OF ALL PERTINENT DATA BY EXAMINER
Physician or Nurse Practitioner to comment on all “yes” answers in questions 7-12 and may develop any additional medical history deemed important and record any significant findings here. (See below for Privacy Act Statement and GINA Notice before proceeding).
Privacy Act Statement: The collection of the information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty. Completion of this form is voluntary;
however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at https://go.fbinet.fbi/DO/OGC/LTB/PCLU/Pages/PCLULibraryMenu.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.
GINA Notice: Do Not Provide Genetic Information, Including Family Medical History
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.
“Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. See 29 C.F.R. § 1635.8(b)(1)(i)(B).
16a. Typed or Printed Name of Physician (MD/DO) or Nurse Practitioner (NP) 16b. Signature of Physician or NP
16c. Date
PLEASE USE ADDITIONAL PAGES IF NECESSARY
FD-1065 - 2 -
https://go.fbinet.fbi/DO/OGC/LTB/PCLU/Pages/PCLULibraryMenu.aspx
| 1 Examinee Legal Name Last First Middle: |
| 2 Date of birth: |
| 4 Examining Facility: |
| 5 Current Medications Dose and Frequency List all medications to include over the counter and herbals NONE check box: |
| 6 Allergies include insect bitesstings and common foods NONE check box: |
| 14a Examinee Legal Name: |
| 16c Date: |
| 7: |
| Do you have any medical condition or physical impairment that could interfere with or otherwise limit your ability in any way to perform your duties fully?: Off |
| 8: |
| Have you ever been admitted or observed overnight in a hospital?: Off |
| 9: |
| Have you had or been advised to have any type of surgery/operation?: Off |
| 10: |
| Have you applied for or are you receiving a pension or compensation for any type of disability?: Off |
| 11: |
| Do you currently have or have you previously had a medical condition that has been evaluated or treated by a clinic, physician, healer, or other practitioner?: Off |
| 12: |
| If you are currently an FBI employee, in the previous two years, have you consulted with or been treated by a clinic, physician, healer, or other practitioner for anything other than minor illness?: Off |
14:
| 6: |
| Allergies: |
| Check this box if there are NO allergies (including insect bites/stings and common foods): Off |
| Explanation of all "Yes" findings by Examinee: |
| 3 DivisionField Office: [ ] |
| Explanation of all "Yes" findings: |
| Date Completed: |
| 5: |
| Current Medications: |
| Check this box if you are NOT taking any medications (including over the counter or herbal): Off |
| 16a Typed or Printed Name of Physician MD/DO or Nurse Practitioner NP: |
| 14c Date Signed: |
File details come from the government source that posted it. Updated .