Designed using Perform Pro, WHS/DIOR, Sep 95
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
First Name Middle Name Jr., II, etc.
2
SOCIAL SECURITY NUMBER
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
No
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?
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
To
Controlled Substance/Prescription Drug Used
Number of Times Used
To
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
No
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
To
Month/Year
Name/Address of Counselor or Doctor State ZIP Code
To
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
No
If you answered "Yes," provide the dates of treatment and the name and address of the therapist or doctor below.
Month/Year
To
Month/Year
Name/Address of Therapist or Doctor State ZIP Code
To
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
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.
