PD F 5521 Investigative Request For Employment Data and Supervisor

PD F 5521 E
Department of the Treasury
Bureau of the Public Debt

INVESTIGATIVE REQUEST FOR EMPLOYMENT
DATA AND SUPERVISOR INFORMATION

OMB No. 1535-0141

U.S. GOVERNMENT USE ONLY

F
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U.S. Department of the Treasury
Bureau of the Public Debt
200 Third Street, Avery 4D
Parkersburg, WV 26106

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INSTRUCTIONS: YOUR NAME HAS BEEN PROVIDED BY THE PERSON IDENTIFIED BELOW TO ASSIST IN COMPLETING A
BACKGROUND INVESTIGATION TO HELP US DETERMINE THIS PERSON’S SUITABILITY FOR EMPLOYMENT OR SECURITY
CLEARANCE. TO HELP US MAKE THIS DETERMINATION, WE ASK THAT YOU COMPLETE ALL ITEMS ON THE BACK OF THIS
FORM AND RETURN THE FORM IN THE ENCLOSED ENVELOPE. WE SEND A SEPARATE INQUIRY TO THE PERSONNEL
OFFICE AND EACH SUPERVISOR SHOWN ON THE PERSON’S APPLICATION; THEREFORE PLEASE DO NOT FORWARD THIS
FOR COMPLETION BY SOMEONE ELSE.
NOTICE UNDER THE PRIVACY ACT: Title 5, Section 301 and Title 31, Section 321, of the U.S. Code authorizes collection of this
information. The purpose for collecting this information is to enable the Bureau of the Public Debt (Public Debt) to make a determination about an individual's suitability for employment or a security clearance. The information you provide may be disclosed to the
person being investigated and to other federal agencies. Furnishing the information on this form is voluntary, but without this information, Public Debt may be unable to make a determination about the individual's suitability for employment or a security clearance.
CERTIFICATION: THE PERSON WE ARE INVESTIGATING HAS GIVEN WRITTEN CONSENT FOR THIS
INVESTIGATIVE INQUIRY. WE KEEP THAT CONSENT ON FILE. IF A COPY IS REQUIRED IN ORDER TO COMPLETE THIS
FORM, OR YOU WOULD LIKE TO KEEP YOUR IDENTITY CONFIDENTIAL, PLEASE INDICATE THIS REQUIREMENT IN WRITING
ON THE REVERSE.
COMPLETION OF THIS INVESTIGATION AS SOON AS POSSIBLE WILL HELP THIS PERSON AND THE AGENCY PERFORM
THEIR DUTIES IN A MORE TIMELY AND EFFICIENT MANNER.

FULL NAME (LAST, FIRST, MIDDLE):
OTHER NAMES USED:

DATE OF BIRTH

SOCIAL SECURITY NUMBER

PLACE OF BIRTH

POSITION FOR WHICH INVESTIGATED:

CLAIMED EMPLOYMENT
FROM

TO

POSITION

NAME OF SUPERVISOR

ACTUAL JOB LOCATION (IF DIFFERENT THAN ABOVE ADDRESS)

We estimate it will take you about 10 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is
displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV
26106-1328. DO NOT SEND completed form to this address. Return the form in the enclosed envelope.

RESET

PLEASE COMPLETE THE ITEMS SHOWN BELOW
IS THE INFORMATION ON THE FRONT OF THIS FORM THE SAME AS SHOWN IN YOUR RECORDS?
a

YES

b

NO (Please explain in item 6)

c

WE HAVE NO RECORD ON THIS PERSON

MARK ONE OF THE FOLLOWING PERTAINING TO THIS PERSON’S EMPLOYMENT:
a

SUBJECT CURRENTLY EMPLOYED HERE

d

LEFT EMPLOYMENT VOLUNTARILY/EMPLOYMENT NOT
ENTIRELY FAVORABLE (Please explain in item 6)

b

LEFT EMPLOYMENT VOLUNTARILY/
EMPLOYMENT ENTIRELY FAVORABLE

e

DISCHARGED FOR UNFAVORABLE EMPLOYMENT
OR CONDUCT

c

DISCHARGED BECAUSE OF COMPANY CUTBACK
IN WORKFORCE OR CHANGE IN SKILL NEEDS

f

RESIGNED AFTER INFORMED OF POSSIBLE DISCHARGE
(Explain in item 6)

g

LEFT EMPLOYMENT BY MUTUAL AGREEMENT DUE
TO SPECIFIC PROBLEMS (Please explain in item 6)

IS THIS PERSON ELIGIBLE FOR REHIRE?
a

YES

c

NO – DUE TO COMPANY POLICY AND/OR
NOT RELATED TO UNFAVORABLE EMPLOYMENT

c

NO – FOR REASONS RELATING TO UNFAVORABLE
EMPLOYMENT (Please explain in item 6)

DO YOU HAVE ANY REASON TO QUESTION THIS PERSON’S HONESTY OR TRUSTWORTHINESS?
a

NO

c

I DO NOT KNOW THIS PERSON WELL ENOUGH TO RESPOND

b

YES (Please explain in item 6)

d

I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

DO YOU HAVE ANY ADVERSE INFORMATION ABOUT THIS PERSON’S EMPLOYMENT, RESIDENCE OR ACTIVITIES CONCERNING:
YES NO

YES NO

a

VIOLATIONS OF THE LAW

c

b

FINANCIAL INTEGRITY

d

YES NO

ABUSE OF ALCOHOL AND/OR DRUGS

e

GENERAL BEHAVIOR OR CONDUCT

MENTAL OR EMOTIONAL STABILITY

f

OTHER MATTERS

(If YES to any of these questions, please explain in item 6)
I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

IF ADDITIONAL INFORMATION IS PROVIDED BELOW, YOU MUST FILL IN THIS MARK.
ADDITIONAL INFORMATION WHICH YOU FEEL MAY HAVE A BEARING ON THIS PERSON’S SUITABILITY FOR GOVERNMENT
EMPLOYMENT OR A SECURITY CLEARANCE. THIS SPACE MAY BE USED FOR DEROGATORY AS WELL AS POSITIVE INFORMATION.

DO YOU RECOMMEND THIS PERSON FOR GOVERNMENT SECURITY CLEARANCE OR EMPLOYMENT?
a

YES

b

NO

PRINT NAME:
PLEASE SIGN THIS FORM HERE:
DAYTIME TELEPHONE NUMBER:

c

I DON’T KNOW THIS PERSON WELL ENOUGH TO MAKE A RECOMMENDATION

YOUR TITLE:
DATE: