fd-864.pdf

FD-864 (Rev. 5-4-98)

FEDERAL BUREAU OF INVESTIGATION

Immunization Questionnaire

Name: ______________________________________________________________ Date: ______________________________

Division: ___________________________________________________________ SSN: ______________________________

Known Medical Problems: ______________________________________________ Blood Type: _________________________

Allergies: ___________________________________________________________

Please respond Yes, No or Unknown to the following questions. If Yes, please place the date, the dosage, facility where given, and person (if known), who gave it to you. If you have traveled overseas you should have all injections listed on your Travel Immunization Record. Some of these are a series of immunizations and some are childhood immunizations. A good resource is the college where you graduated.

Have you ever been immunized or had any of the following?

Immunization Yes No Unk Date Dosage Facility Where Injection Given Person Giving Injection

Diphtheria/Tetanus (Td)

Dose one

Dose two

Dose three

Hepatitis A (Havrix or VAQTA)

Dose one

Dose two

Hepatitis B

Dose one

Dose two

Dose three

Influenza

Measles (3 days) (Rubella)

Measles (9 days) (Rubeola)

Meningococcal Meningitis (MM)

MMR (Measles, Mumps, Rubella)

FBI/DOJ

Immunization Yes No Unk Date Dosage Facility Where Injection Given Person Giving Injection

Pertussis (Whooping Cough)

Dose one

Dose two

Dose three

Polio

Dose one

Dose two

Dose three

Adult Booster (OPV)

Rabies

Pre Exposure

Dose one

Dose two

Dose three

Post Exposure

Dose one

Dose two

Dose three

Dose four

Booster

Typhoid (oral)

Yellow Fever

Japanese Encephalitis

Other

Privacy Act Statement

Authority and Principal Purposes for which Information is Intended to be Used

Authority for maintenance of these records includes 5 U. S. C. §§ 3301 and 7901; 5 C. F. R. §§ 293 and 297; and 28 C. F. R. § 0.137. Providing this personal information will facilitate and document your health care. The information you furnish will be maintained in your medical file in order to ensure that your medical history is current, and that no condition exists which would interfere with the performance of duty in a position involving a high degree of responsibility toward the public or sensitive national security concerns. The immunization record must be maintained and updated in the event that the nature of your duties requires exposure to chemical substances, fluids, or other dangerous materials, or in the event that your duties require overseas travel which would increase your risk to communicable diseases.

Routine Uses The primary use of this information is to provide, plan, and coordinate health care, as necessary. Other possible uses include: Aid in preventive health and communicable disease control programs and reporting medical conditions required by law to federal, state, and local agencies; compile statistical data; determine suitability of persons for duties or assignments; adjudicate claims and determine benefits; other lawful purposes, including law enforcement and litigation; conduct authorized investigations; evaluate care rendered; those routine uses as published in the notice for the FBI’s Central Records System in the Federal Register; and other uses as established by the Office of Personnel Management for its records system, OPM/GOVT-10 - Employee Medical File System Records.

Effects of Nondisclosure

For employees in or applying for positions for which medical qualifications or standards have been established, disclosure is mandatory. Failure to provide the requested information may lead to disqualification for the position.

For others, disclosure of the requested information is voluntary. If the requested information is not furnished, it will be more difficult to provide health care as necessary; however, such care will not, unless otherwise indicated, be denied.

Social Security Number

The Social Security Number (SSN) is utilized to identify and retrieve health care records, and to maintain the overall accuracy of Bureau health records. Solicitation of the SSN is authorized under provisions of Executive Order 9397, dated November 22, 1943. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. The use of the SSN is made necessary because of the large number of present and former federal employees, and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.

Your signature acknowledges that you have been advised of the foregoing.

Signature Social Security Number

Date Signed

Enclosure