Supplemental Questionnaire for Selected Positions Standard Form 85P SRevised December 2017U S Office of Personnel Management5 CF 2017-2026

Other than this restriction to its use this form has the same purposes and authorities described on SF 85P. Do not send your completed form to this address. IDENTIFICATION INFORMATION FULL NAME Enter your name exactly as it appears on your SF 85P Questionnaire for Public Trust Positions. 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. Standard Form 85P-S EG Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731 732 and 736 Form approved OMB No. 3206-0191 NSN 7540-01-368-7778 85-1700 Supplemental Questionnaire for Selected Positions 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. 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. Last Name First Name Middle Name SOCIAL SECURITY NUMBER Jr. II etc* SUPPLEMENTAL QUESTIONS 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 No 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 codeine heroin etc* amphetamines depressants barbiturates methaqualone tranquilizers etc* hallucinogenics LSD PCP etc* or prescription drugs b Yes Have you ever illegally used a controlled substance while employed as a law enforcement officer prosectutor 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 Controlled Substance/Prescription Drug Used Number of Times Used To 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 Name/Address of Counselor or Doctor State ZIP Code YOUR MEDICAL RECORD 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.