fd-864 rev 032010.pdf

FD-864 (Rev. 3-8-2010)

FEDERAL BUREAU OF INVESTIGATION

Immunization Questionnaire

Name: ______________________________________________________________ Date: ___________________

Division: __________________________________________________ Employee ID#: _____________________

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)

Hepatitis B

Dose one

Dose two

Dose three

Influenza

Measles (3 days) (Rubella)

Measles (9 days) (Rubeola)

Meningococcal Meningitis (MM)

MMR (Measles, Mumps, Rubella)

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

Pertussis (Whooping Cough)

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.

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

Signature Employee ID#

Date Signed

Enclosure