Attachment 17 Standard Form 85P S Supplemental Questionnaire for Selected Positions.pdf

Form approved:

OMB No. 3206 0258 SUPPLEMENTAL QUESTIONNAIRE

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

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.

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.

Section 1 - Full Name (Enter your full name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions.)

IDENTIFICATION INFORMATION

Section 3 - Your Use of Illegal Drugs and Drug Activity

Section 4 - Your Use of Alcohol

SUPPLEMENTAL QUESTIONS

Section 2 - Social Security Number

Social Security Number

We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity not in accordance with Federal laws, even though permissible under state laws.

Since the age of 16 or in the last 5 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?

YES NO

YES NO

YES NO

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.

If you answered "Yes", provide the dates of treatment and the name and address of the counselor below.

(a)

(b)

To

To

To

To

Month/Year Month/Year Controlled Substance/Prescription Drug Used Number of Times Used

Month/Year Month/Year Name/Address of the Counselor or Doctor State Zip Code

In the last 5 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)?

SuffixMiddle nameFirst nameLast name

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

(Month/Year)

Zip Code

Zip Code

Provide the name of the court or administrative agency that declared you mentally incompetent.

Est.

Provide the name of the court or administrative agency. Provide the final disposition.

Provide the name of the court or administrative agency. Provide the final disposition.

Section 5 - Psychological and Emotional Health

5A

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. Every day individuals with mental health conditions carry out their duties without presenting a security risk. While most individuals with mental health conditions do not present security risks, there may be times when such a condition can affect a person’s eligibility for a security clearance.

Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce, major injury, service in a military combat environment, sexual assault, domestic violence, or other difficult work-related, family, personal, or medical issues may lead to grief, depression, or other responses. The government recognizes that mental health counseling and treatment may provide important support for those who have experienced such events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage those who might benefit from such treatment from seeking it.

Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems. Seeking or receiving mental health care for personal wellness and recovery may contribute favorably to decisions about your eligibility.

Has a court or administrative agency EVER issued an order declaring you mentally incompetent?

YES NO

Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.

Provide the date this occurred.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Appeal #1

Appeal #2

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Entry #1

CountryStateCityStreet

CountryStateCityStreet

YES NO (If NO, proceed to Section 5B)

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Section 5A - Psychological and Emotional Health - (Continued)

Zip Code

Zip Code

Provide the name of the court or administrative agency that declared you mentally incompetent.

Est.

Provide the name of the court or administrative agency. Provide the final disposition.

Provide the name of the court or administrative agency.

(Month/Year)

Provide the final disposition.

YES NO

Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.

Provide the date this occurred.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Appeal #1

Appeal #2

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Entry #2

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

(Month/Year)

Section 5A - Psychological and Emotional Health - (Continued)

Zip Code

Zip Code

Provide the name of the court or administrative agency that declared you mentally incompetent.

Est.

Provide the name of the court or administrative agency. Provide the final disposition.

Provide the name of the court or administrative agency. Provide the final disposition.

YES NO

Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.

Provide the date this occurred.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Appeal #1

Appeal #2

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Entry #3

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Zip Code

Zip Code

Provide the name of the court or administrative agency that ordered you to consult with a mental health professional.

Est.

Provide the name of the court or administrative agency. Provide the final disposition.

Provide the name of the court or administrative agency. Provide the final disposition.

Section 5B - Psychological and Emotional Health - (Continued)

5B

(Month/Year)

Has a court or administrative agency EVER ordered you to consult with a mental health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, etc.)?

(An order to a military member by a superior officer is not within the scope of this question, and therefore would not require an affirmative response. An order by a military court would be within the scope of the question and would require an affirmative response.)

YES NO

Complete the following if you answered 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.

Provide the date this occurred.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Appeal #1

Appeal #2

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Entry #1

CountryStateCityStreet

YES NO (If NO, proceed to Section 5C)

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Zip Code

Zip Code

Provide the name of the court or administrative agency that ordered you to consult with a mental health professional.

Est.

Provide the name of the court or administrative agency. Provide the final disposition.

Provide the name of the court or administrative agency. Provide the final disposition.

Section 5B - Psychological and Emotional Health - (Continued)

(Month/Year)

YES NO

Complete the following if you answered 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.

Provide the date this occurred.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Appeal #1

Appeal #2

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Entry #2

CountryStateCityStreet

Provide the final disposition.

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Provide the name of the facility where treatment was provided.

Explanation

Explanation

Involuntary

Voluntary

Provide the dates of treatment.

Entry #2

Zip Code CountryStateCityStreet Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Est.

Est.

Present

Was the admission voluntary or involuntary?

To Date (Month/Year)

From Date (Month/Year)

Provide the name of the facility where treatment was provided.

From Date (Month/Year)

To Date (Month/Year)

Was the admission voluntary or involuntary?

Present

Est.

Est.

Section 5C - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to having EVER been hospitalized for a mental health condition.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Entry #1

5C Have you EVER been hospitalized for a mental health condition? YES NO (If NO, proceed to Section 5D)

Provide the dates of treatment.

Voluntary

Involuntary

Explanation

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Provide the name of the facility where treatment was provided.

Explanation

Explanation

Involuntary

Voluntary

Provide the dates of treatment.

Entry #4

Zip Code CountryStateCityStreet Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Est.

Est.

Present

Was the admission voluntary or involuntary?

To Date (Month/Year)

From Date (Month/Year)

Provide the name of the facility where treatment was provided.

From Date (Month/Year)

To Date (Month/Year)

Was the admission voluntary or involuntary?

Present

Est.

Est.

Section 5C - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to having EVER been hospitalized for a mental health condition.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Entry #3

Provide the dates of treatment.

Voluntary

Involuntary

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Identify the diagnosis or health condition.

ExtensionTelephone number

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

Est.

Section 5D - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State CountryZip Code

Entry #1

5D Have you EVER been diagnosed by a physician or other health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic disorder, schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder, borderline personality disorder, or antisocial personality disorder?

YES NO (If NO, proceed to Section 5E)

Provide the dates of diagnosis.

The following question asks whether you have been diagnosed with a specified mental health condition that may, particularly if untreated, impact your judgment, reliability, or trustworthiness. If you answer in the affirmative, we will seek additional information about the seriousness and symptoms of the condition, as well as any applicable course of treatment. It is important to note that any such diagnosis, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems.

Provide the name of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Same as above

Same as Above

Provide the telephone number of the agency/organization/facility.

International or DSN phone number

NightDay

ExtensionTelephone number

Same as above

YES NO Explanation

Was the counseling/treatment effective in managing your symptoms?

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Identify the diagnosis or health condition.

ExtensionTelephone number

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

Est.

Section 5D - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State CountryZip Code

Entry #2

Provide the dates of diagnosis.

Provide the name of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Same as above

Same as above

Provide the telephone number of the agency/organization/facility.

International or DSN phone number

NightDay

ExtensionTelephone number

Same as above

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Identify the diagnosis or health condition.

ExtensionTelephone number

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

Est.

Section 5D - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State CountryZip Code

Entry #3

Provide the dates of diagnosis.

Provide the name of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Same as above

Same as above

Provide the telephone number of the agency/organization/facility.

International or DSN phone number

NightDay

ExtensionTelephone number

Same as above

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Identify the diagnosis or health condition.

ExtensionTelephone number

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

Est.

Section 5D - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State CountryZip Code

Entry #4

Provide the dates of diagnosis.

Provide the name of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Same as above

Same as above

Provide the telephone number of the agency/organization/facility.

International or DSN phone number

NightDay

ExtensionTelephone number

Same as above

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Extension

Extension

Day Night

International or DSN phone number

Provide the telephone number of the health care professional.Provide the name of the health care professional providing such treatment.

Entry #4

Zip Code CountryStateCityStreet

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Telephone number Extension

Telephone number

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State CountryZip Code

Entry #3

Provide the name of the health care professional providing such treatment.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Day Night

International or DSN phone number

Provide the telephone number of the health care professional.Provide the name of the health care professional providing such treatment.

Entry #2

Zip Code CountryStateCityStreet

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Telephone number Extension

Telephone number

Section 5D - Psychological and Emotional Health - (Continued)

Complete the following if you answered 'Yes' to currently being in treatment.

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State CountryZip Code

Entry #1

5D.1 Are you currently in treatment?

YES NO (If NO, proceed to Section 5E)

YES NO (If NO, proceed to Section 5E)

In the last seven years, have there been any occasions when you did not consult with a medical professional before altering or discontinuing, or failing to start a prescribed course of treatment for any of the listed diagnoses?

Provide the name of the health care professional providing such treatment.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Extension

#2

Same as above

Telephone number Extension Day Night

International or DSN phone number

Provide the telephone number of the agency/organization/facility.

Same as AboveSame as above

Day Night

International or DSN phone number

Provide the telephone number of the health care professional.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the name of the health care professional.

Provide the dates of counseling or treatment

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Est.

Est.

Present

To Date (Month/Year)From Date (Month/Year) Telephone number Extension

Telephone number From Date (Month/Year) To Date (Month/Year)

Present

Est.

Est.

Section 5E - Psychological and Emotional Health - (Continued)

Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State CountryZip Code

Entry #1

5E Do you have a mental health or other health condition that substantially adversely affects your judgment, reliability, or trustworthiness even if you are not experiencing such symptoms today? YES NO (If NO, proceed to Certification)

Provide the dates of counseling or treatment

Complete the following if you responded 'No' to 5A, 5B, 5C, and 5D (All). If 'Yes' was selected for either 5A, 5B, 5C, or 5D, (any of them), proceed to Certification.

Provide the name of the health care professional.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Same as above Same as Above Provide the telephone number of the agency/organization/facility.

International or DSN phone number

NightDay ExtensionTelephone number

Same as above

(Note: If your judgment, reliability, or trustworthiness is not substantially adversely affected by a mental health or other condition, then you should answer "no" even if you have a mental health or other condition requiring treatment. For example, if you are in need of emotional or mental health counseling as a result of service as a first responder, service in a military combat environment, having been sexually assaulted or a victim of domestic violence, or marital issues, but your judgment, reliability or trustworthiness is not substantially adversely affected, then answer "no.")

YES

NO

I decline to answer (If I decline to answer, proceed to Certification)

Explanation

If you responded 'Yes' to having ever received or you are currently receiving counseling or treatment for that condition.

#1

Have you ever chosen not to follow a prescribed course of treatment for any of these conditions?

If YES provide explanationYES

NO

Did you ever receive or are you currently receiving counseling or treatment for that condition? (You may choose not to answer this question. However, such consultation or treatment will not disqualify you and is considered to be a positive action.)

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Extension

#2

Same as above

Telephone number Extension

Day Night

International or DSN phone number

Provide the telephone number of the agency/organization/facility.

Same as Above Same as above

Day Night

International or DSN phone number

Provide the telephone number of the health care professional.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the name of the health care professional.

Provide the dates of counseling or treatment

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State CountryZip Code

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Est.

Est.

Present

To Date (Month/Year)From Date (Month/Year) Telephone number Extension

Telephone number From Date (Month/Year) To Date (Month/Year)

Present

Est.

Est.

Section 5E - Psychological and Emotional Health - (Continued)

Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Zip Code CountryStateCityStreet

Provide the address of agency/organization/facility where counseling/treatment was provided.

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State CountryZip Code

Entry #2

Provide the dates of counseling or treatment

Provide the name of the health care professional.

Provide the name of any agency/organization/facility where counseling/treatment was provided.

Provide the telephone number of the health care professional.

International or DSN phone number

NightDay

Same as above Same as Above

Provide the telephone number of the agency/organization/facility.

International or DSN phone number

NightDay

ExtensionTelephone number

Same as above

If you responded 'Yes' to having ever received or you are currently receiving counseling or treatment for that condition.

#1

Have you ever chosen not to follow a prescribed course of treatment for any of these conditions?

If YES provide explanationYES

NO

FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

CERTIFICATION

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).

Certification That My Answers Are True

DateSignature (Sign in ink)

Form approved: OMB No. 3206 0258

SUPPLEMENTAL QUESTIONNAIRE FOR SELECTED POSITIONS

Standard Form 85P-S Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Page

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.

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.

Section 1 - Full Name (Enter your full name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions.)

IDENTIFICATION INFORMATION

Section 3 - Your Use of Illegal Drugs and Drug Activity Section 4 - Your Use of Alcohol

SUPPLEMENTAL QUESTIONS

Section 2 - Social Security Number We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity not in accordance with Federal laws, even though permissible under state laws.

Since the age of 16 or in the last 5 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?

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.

If you answered "Yes", provide the dates of treatment and the name and address of the counselor below.

(a) (b) To To To To Month/Year Month/Year Controlled Substance/Prescription Drug Used Number of Times Used Month/Year Month/Year Name/Address of the Counselor or Doctor State Zip Code In the last 5 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)?

(Month/Year) Section 5 - Psychological and Emotional Health 5A 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. Every day individuals with mental health conditions carry out their duties without presenting a security risk. While most individuals with mental health conditions do not present security risks, there may be times when such a condition can affect a person’s eligibility for a security clearance.

Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce, major injury, service in a military combat environment, sexual assault, domestic violence, or other difficult work-related, family, personal, or medical issues may lead to grief, depression, or other responses. The government recognizes that mental health counseling and treatment may provide important support for those who have experienced such events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage those who might benefit from such treatment from seeking it.

Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems. Seeking or receiving mental health care for personal wellness and recovery may contribute favorably to decisions about your eligibility.

Has a court or administrative agency EVER issued an order declaring you mentally incompetent?

Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Appeal #1 Appeal #2 Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #1 Section 5A - Psychological and Emotional Health - (Continued) (Month/Year) Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Appeal #1 Appeal #2 Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #2 (Month/Year) Section 5A - Psychological and Emotional Health - (Continued) Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Appeal #1 Appeal #2 Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #3 Section 5B - Psychological and Emotional Health - (Continued) 5B (Month/Year) Has a court or administrative agency EVER ordered you to consult with a mental health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, etc.)? (An order to a military member by a superior officer is not within the scope of this question, and therefore would not require an affirmative response. An order by a military court would be within the scope of the question and would require an affirmative response.)

Complete the following if you answered 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Appeal #1 Appeal #2 Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #1 Section 5B - Psychological and Emotional Health - (Continued) (Month/Year) Complete the following if you answered 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was this matter appealed to a higher court or administrative agency?

Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Appeal #1 Appeal #2 Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #2 arrow pointing right .\right arrow.png arrow pointing right .\right arrow.png arrow pointing right .\right arrow.png arrow pointing right .\right arrow.png Provide the dates of treatment.

Entry #2 Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was the admission voluntary or involuntary?

Was the admission voluntary or involuntary?

Section 5C - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to having EVER been hospitalized for a mental health condition.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #1 5C Have you EVER been hospitalized for a mental health condition?

Provide the dates of treatment.

arrow pointing right .\right arrow.png arrow pointing right .\right arrow.png arrow pointing right .\right arrow.png arrow pointing right .\right arrow.png Provide the dates of treatment.

Entry #4 Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Was the admission voluntary or involuntary?

Was the admission voluntary or involuntary?

Section 5C - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to having EVER been hospitalized for a mental health condition.

Provide the address of the facility where treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #3 Provide the dates of treatment.

arrow pointing right .\right arrow.png Section 5D - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #1 5D Have you EVER been diagnosed by a physician or other health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic disorder, schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder, borderline personality disorder, or antisocial personality disorder?

Provide the dates of diagnosis.

The following question asks whether you have been diagnosed with a specified mental health condition that may, particularly if untreated, impact your judgment, reliability, or trustworthiness. If you answer in the affirmative, we will seek additional information about the seriousness and symptoms of the condition, as well as any applicable course of treatment. It is important to note that any such diagnosis, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems.

Provide the telephone number of the health care professional.

Provide the telephone number of the agency/organization/facility.

Was the counseling/treatment effective in managing your symptoms?

Section 5D - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #2 Provide the dates of diagnosis.

Provide the telephone number of the health care professional.

Provide the telephone number of the agency/organization/facility.

arrow pointing right .\right arrow.png Was the counseling/treatment effective in managing your symptoms?

Section 5D - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #3 Provide the dates of diagnosis.

Provide the telephone number of the health care professional.

Provide the telephone number of the agency/organization/facility.

arrow pointing right .\right arrow.png Was the counseling/treatment effective in managing your symptoms?

Section 5D - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to having EVER been diagnosed by a physician or other health professional.

Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #4 Provide the dates of diagnosis.

Provide the telephone number of the health care professional.

Provide the telephone number of the agency/organization/facility.

arrow pointing right .\right arrow.png Was the counseling/treatment effective in managing your symptoms?

Provide the telephone number of the health care professional.

Entry #4 Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Entry #3 Provide the telephone number of the health care professional.

Provide the telephone number of the health care professional.

Entry #2 Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Section 5D - Psychological and Emotional Health - (Continued) Complete the following if you answered 'Yes' to currently being in treatment.

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Entry #1 5D.1 Are you currently in treatment?

In the last seven years, have there been any occasions when you did not consult with a medical professional before altering or discontinuing, or failing to start a prescribed course of treatment for any of the listed diagnoses?

Provide the telephone number of the health care professional.

#2 Provide the telephone number of the agency/organization/facility.

Provide the telephone number of the health care professional.

Provide the dates of counseling or treatment Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Section 5E - Psychological and Emotional Health - (Continued) Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.

Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Entry #1 5E Do you have a mental health or other health condition that substantially adversely affects your judgment, reliability, or trustworthiness even if you are not experiencing such symptoms today?

Provide the dates of counseling or treatment Complete the following if you responded 'No' to 5A, 5B, 5C, and 5D (All). If 'Yes' was selected for either 5A, 5B, 5C, or 5D, (any of them), proceed to Certification.

Provide the telephone number of the health care professional.

Provide the telephone number of the agency/organization/facility.

(Note: If…