Supplemental Questionnaire for Selected Positions Standard Form 85P-S (EG) Revised September 1995 OMB No. 3206-0191 Form approved: 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: you must type or legibly print your answers in black ink, use State codes, etc. Be sure to sign and date the certification statement at the bottom of this page. 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. IDENTIFICATION INFORMATION 1 FULL NAME Enter your name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions. Last Name (Question 1. Box 1 of 4. Enter your last name.) First Name (Question 1. Box 2 of 4. Enter your first name.) Middle Name (Question 1. Box 3 of 4. Enter your middle name.) Jr., II, etc. (Question 1. Box 4 of 4. Enter your name suffix (jr, II, etc.).) 2 SOCIAL SECURITY NUMBER (Question 2. Enter Social Security Number Using (999-99-9999).) SUPPLEMENTAL QUESTIONS 3 YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you, but neither your truthful response nor information derived from your response will be used as evidence against you in any subsequent criminal proceeding. a Since the age of 16 or in the last 7 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? Yes (Question 3a. Box 1 of 2. Press the space bar to indicate "Yes" you have illegally used controlled substances or prescription drugs.) Unchecked No (Question 3a. Box 2 of 2. Press the space bar to indicate "No" you have not illegally used controlled substances or prescription drugs.) Unchecked b 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? (Question 3b. Box 1 of 2. Press the space bar to indicate "Yes" you have illegally used controlled substances or prescription drugs while employed.) Unchecked (Question 3b. Box 2 of 2. Press the space bar to indicate "No" you have not illegally used controlled substances or prescription drugs while employed.) Unchecked 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. Month/Year Month/Year (Question 3. Line 1 of 2, Box 1 of 4. Enter Dates of Substance and/or Prescription Drug From Using (mm/yyyy).) To (Question 3. Line 1 of 2, Box 2 of 4. Enter Dates of Substance and/or Prescription Drug To Using (mm/yyyy).) Controlled Substance/Prescription Drug Used (Question 3. Line 1 of 2, Box 3 of 4. Enter Substance and/or Prescription Drug Used.) Number of Times Used (Question 3. Line 1 of 2, Box 4 of 4. Enter Number of Times Substance and/or Prescription Drug Used.) (Question 3. Line 2 of 2, Box 1 of 4. Enter Dates of Substance and/or Prescription Drug From Using (mm/yyyy).) To (Question 3. Line 2 of 2, Box 2 of 4. Enter Dates of Substance and/or Prescription Drug To Using (mm/yyyy).) (Question 3. Line 2 of 2, Box 3 of 4. Enter Substance and/or Prescription Drug Used.) (Question 3. Line 2 of 2, Box 4 of 4. Enter Number of Times Substance and/or Prescription Drug Used.) 4 YOUR USE OF ALCOHOL In the last 7 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)? Yes (Question 4. Box 1 of 2. Press the space bar to indicate "Yes" you have been treated for use of alcohol.) Unchecked No (Question 4. Box 2 of 2. Press the space bar to indicate "No" you have not been treated for use of alcohol.) Unchecked If you answered "Yes," provide the dates of treatment and the name and address of the counselor below. Do not repeat information reported in Month/Year (Question 4. Line 1 of 2, Box 1 of 5. Enter Dates of Treatment From Using (mm/yyyy).) To Month/Year (Question 4. Line 1 of 2, Box 2 of 5. Enter Dates of Treatment To Using (mm/yyyy).) Name/Address of Counselor or Doctor (Question 4. Line 1 of 2, Box 3 of 5. Enter Name and Address of Counselor or Doctor.) State (Question 4. Line 1 of 2, Box 4 of 5. Enter State of Counselor or Doctor.) ZIP Code (Question 4. Line 1 of 2, Box 5 of 5. Enter Zip Code of Counselor or Doctor.) (Question 4. Line 2 of 2, Box 1 of 5. Enter Dates of Treatment From Using (mm/yyyy).) To (Question 4. Line 2 of 2, Box 2 of 5. Enter Dates of Treatment To Using (mm/yyyy).) (Question 4. Line 2 of 2, Box 3 of 5. Enter Name and Address of Counselor or Doctor.) (Question 4. Line 2 of 2, Box 4 of 5. Enter State of Counselor or Doctor.) (Question 4. Line 2 of 2, Box 5 of 5. Enter Zip Code of Counselor or Doctor.) 5 YOUR MEDICAL RECORD In the last 7 years, have you consulted with a mental health professional (psychiatrist, psychologist, counselor, etc.) or have you consulted with another health care provider about a mental health related condition? You do not have to answer "Yes" if you were only involved in marital, grief, or family counseling not related to violence by you. Yes (Question 5. Box 1 of 2. Press the space bar to indicate "Yes" you have been been involved in marital, grief, or family counseling.) Unchecked No (Question 5. Box 2 of 2. Press the space bar to indicate "No" you have not been been involved in marital, grief, or family counseling.) Unchecked If you answered "Yes," provide the dates of treatment and the name and address of the therapist or doctor below. Month/Year (Question 5. Line 1 of 2, Box 1 of 5. Enter Dates of Treatment From Using (mm/yyyy).) To Month/Year (Question 5. Line 1 of 2, Box 2 of 5. Enter Dates of Treatment To Using (mm/yyyy).) Name/Address of Therapist or Doctor (Question 5. Line 1 of 2, Box 3 of 5. Enter Name and Address of Therapist or Doctor.) State (Question 5. Line 1 of 2, Box 4 of 5. Enter State of Therapist or Doctor.) ZIP Code (Question 5. Line 1 of 2, Box 5 of 5. Enter Zip Code of Therapist or Doctor.) (Question 5. Line 2 of 2, Box 1 of 5. Enter Dates of Treatment From Using (mm/yyyy).) To (Question 5. Line 2 of 2, Box 2 of 5. Enter Dates of Treatment To Using (mm/yyyy).) (Question 5. Line 2 of 2, Box 3 of 5. Enter Name and Address of Therapist or Doctor.) (Question 5. Line 2 of 2, Box 4 of 5. Enter State of Therapist or Doctor.) (Question 5. Line 2 of 2, Box 5 of 5. Enter Zip Code of Therapist or Doctor.) CERTIFICATION Certification That My Answers Are True 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). Signature (Sign in ink) Date (Certification. Enter Date of Signature Using (mm/dd/yyyy).) U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 NSN 7540-01-368-7778 85-1700 Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995. (This is the print button. Press the space bar to print this form.) Print Form (This is the save button. Press the space bar to save this form.) Save Form (This is the last field on this form. This is the clear button. Press the space bar to clear the data on this form.) Clear Form