Standart Form 85P S – Fill Out and Use This PDF

Standard Form 85P-S (EG)	Form approved
Revised September 1995	OMB No. 3206-0191
U.S. Office of Personnel Management	NSN 7540-01-368-7778
5 CFR Parts 731, 732, and 736	85-1700

Supplemental Questionnaire for Selected Positions

IDENTIFICATION INFORMATION

	1	FULL NAME	Enter your name exactly as it appears on your SF 85P, Questionnaire for Public Trust Positions.				2 SOCIAL SECURITY NUMBER
	Last Name			First Name	Middle Name	Jr., II, etc.
	SUPPLEMENTAL QUESTIONS
		YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY
	3							Yes	No
		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.

aSince 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?

bHave 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.

To

4 YOUR USE OF ALCOHOL

Yes

No

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)?

If you answered "Yes," provide the dates of treatment and the name and address of the counselor below.

			Month/Year	Month/Year	Name/Address of Counselor or Doctor	State ZIP Code
				To
				To
						Yes	No
	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.

If you answered "Yes," provide the dates of treatment and the name and address of the therapist or doctor below.

Month/Year

Month/Year

Name/Address of Therapist or Doctor

State

ZIP Code

To

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).

Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995. Designed using Adobe LiveCycle Designer 7.1