Federal Bureau of Investigaton Bioterrorism Preparedness Act Entity/Individual Information

INSTRUCTIONS

Accessing the FD-961 Form and Instructions

The FD-961 Form and these instructions can be accessed at the FBI, Criminal Justice Information Services (CJIS) Division web page at www.fbi.gov/about-us/cjis/bioterrorism-security-risk-assessment-form.

Requesting Fingerprint Cards

Fingerprint card packages can be obtained by faxing a request to the CJIS Division at 304-625-3984. The request should include the following: entity name, point of contact, mailing address, contact's telephone number and quantity of requested bioterrorism fingerprint card packages.

Requirements for New or Inactive Applicants

For applicants that do not have an active Security Risk Assessment (SRA) on file with the Bioterrorism Risk Assessment Group (BRAG), the FD-961 Form and two legible fingerprint cards must be completed and mailed as one package to:

Bioterrorism Risk Assessment Group, Module E-3

Criminal Justice Information Services Division

Federal Bureau of Investigation

1000 Custer Hollow Road

Clarksburg, WV 26306

Requirements for Active Applicants

If the applicant has an active SRA on file with BRAG, the FD-961 Form can be completed and faxed to BRAG at 304-625-2198. Fingerprint cards are not required; however, BRAG reserves the right to request additional fingerprint cards if necessary.

Federal Select Agent Program (FSAP) Information

Please refer to the APHIS/CDC National Select Agent website at www.selectagents.gov or contact your APHIS or CDC Representative for questions regarding the FSAP. General guidance can be found at the website including who requires an SRA, obtaining a Unique Identifying Number (UIN), expediting an SRA, and other frequently asked questions.

Completion of FD-961 Form

Please note that incomplete, expired (Rev. 12-05-2012 and earlier) or outdated forms (signature date exceeds 90 days) will not be processed.

Section I:

1. Provide the legal name of the entity and the entity registration number supplied by APHIS or CDC (AGRXXXXXX or CDCXXXXXX).

2. Provide the physical address for the entity including street, city, state and zip code.

Section II:

3. Provide the UIN supplied by APHIS or CDC, formerly known as the DOJ Number. APHIS or CDC provides the UIN for each individual listed on the APHIS/CDC Form 1 to the RO.

4. Applicant's full name (last, first, middle, and suffix, e.g. Jr. or III). The name provided in block 4 should be identical to that listed on the APHIS/CDC Form 1.

4a. List all Aliases/Maiden names.

5. Provide date of birth.

6. Social security number.

7. Applicant's physical residential address including street, city, state and zip code. Forms received with a foreign address will not be processed.

7a. Indicate if applicant has any additional states of residence.

7b. List all states that the applicant resided in as an adult (18 yrs of age and older).

Please note that forms submitted prior to a foreign national’s entry into the U.S. will return an immigration check result of "no record of legal entry into the U.S." The SRA will be completed and the individual will be identified as a restricted person (unlawful or illegal alien). If a foreign national will be in the U.S. briefly and completion of the SRA is urgent, an expedited SRA request can be submitted to APHIS or CDC once the individual enters the country.

10. Applicant's city and state, or country of birth. If the applicant is a national of more than one country, list each country of citizenship. Additionally, list any citizenship(s) that the applicant has renounced.

11. If born to a US citizen serving a military or diplomatic post in a foreign country please include a copy of the US Citizen Born Abroad Certificate with the FD-961 Form.

Alien registration or admission numbers are issued by the Bureau of Immigration and Customs Enforcement for individuals who are granted lawful permanent resident or naturalized citizen statuses in the U.S. Other situations that individuals would have an alien registration or admission number include the following: Employment Authorization Cards, Temporary Resident Cards, Border Crossing Cards,

I-94 or Visa Numbers.

The most common immigration statuses include: naturalized citizen, lawful permanent resident, student ( F1), exchange visitor (J1), or temporary specialty worker (H1, H1B). The status expiration date is also referred to as the "admitted until" date. Temporary statuses may list "duration of status" as an expiration date. Please include this in the status expiration field on the form.

Section III:

18 U.S.C. § 1001 states that knowingly and willfully falsifying or concealing a material fact is a felony that may result in fines or imprisonment for not more than 5 years or both.

12a – 12j: Answer all questions with a "yes", "no" or “unsure” in the boxes provided. FD-961 Forms with questions left blank will not be processed.

If the applicant is not sure how to answer any question, they should check "not sure". For any questions answered “yes” or "not sure", the applicant must provide additional information or supporting documentation to assist BRAG in processing the SRA. This information can include court documents, arresting agency information, arrest date, charges, etc. For medical documentation the applicant should contact the medical facility, sign a release and have the medical facility mail the documentation directly to BRAG.

12a. Indictment - Includes an indictment or information in any court, under which a crime punishable by imprisonment for a term exceeding 1 year may be prosecuted, or in military cases to any offense punishable by imprisonment for a term exceeding 1 year which has been referred to a general court-martial. An information is a formal accusation of a crime, differing from an indictment in that it is made by a prosecuting attorney and not a grand jury.

12a. &b. Crime punishable by imprisonment for a term exceeding 1 year - Any Federal, State or foreign offense for which the maximum penalty, whether or not imposed, is capital punishment or imprisonment in excess of 1 year. What constitutes a conviction of such a crime shall be determined in accordance with the law of the jurisdiction in which the proceedings were held. Any conviction which has been expunged or set aside or for which a person has been pardoned shall not be considered a conviction.

12c. Fugitive from justice - Any person who has an active want or warrant, regardless of reason (to avoid prosecution for a felony or misdemeanor, or to avoid giving testimony in any criminal proceeding, etc).

12d. Unlawful user of or addicted to any controlled substance - A person who uses a controlled substance and has lost the power of self-control with reference to the use of controlled substance; and any person who is a current user of a controlled substance in a manner other than prescribed by a licensed physician. Such use is not limited to the use of drugs on a particular day, or within a matter of days or weeks before, but rather that the unlawful use has occurred recently enough to indicate that the individual is actively engaged in such conduct. A person may be an unlawful current user of a controlled substance even though the substance is not being used at the precise time the person seeks access to biological select agents and toxins. An inference of current use may be drawn from evidence of a recent use or possession of a controlled substance or a pattern of use or possession that reasonably covers the present time, e.g., a conviction for use or possession of a controlled substance within the past year; multiple arrests for such offenses within the past 5 years if the most recent arrest occurred within the past year; or persons found through a drug test to use a controlled substance unlawfully, provided that the test was administered within the past year. For a current or former member of the Armed Forces, an inference of current use may be drawn from recent disciplinary or other administrative action based on confirmed drug use, e.g., court-martial conviction, nonjudicial punishment, or an administrative discharge based on drug use or drug rehabilitation failure.

Controlled Substance – A drug or other substance, or immediate precursor, as defined in section 102 of the Controlled Substances Act, 21 U.S.C. 802. The term includes, but is not limited to, marijuana, depressants, stimulants, and narcotic drugs. The term does not include distilled spirits, wine, malt beverages, or tobacco, as those terms are defined or used in Subtitle E of the Internal Revenue Code of 1954, as amended.

12e. Adjudicated as a mental defective – (a) A determination by a court, board, commission, or other lawful authority that a person, as a result of marked subnormal intelligence, or mental illness, incompetency, condition or disease: (1) is a danger to himself or to others; or (2) lacks the mental capacity to contract or manage his own affairs. (b) The term shall include (1) a finding of insanity by a court in a criminal case; and (2) those persons found incompetent to stand trial or found not guilty by reason of lack of mental responsibility pursuant to articles 50a and 72b of the Uniform Code of Military Justice, 10 U.S.C. 850a, 876b.

Committed to a mental institution – A formal commitment of a person to a mental institution by a court, board, commission, or other lawful authority. The term includes a commitment to a mental institution involuntarily. The term includes commitment for mental defectiveness or mental illness. It also includes commitments for other reasons, such as for drug use. The term does not include a person in a mental institution for observation or a voluntary admission to a mental institution.

Mental institution – Includes mental health facilities, mental hospitals, sanitariums, psychiatric facilities, and other facilities that provide diagnoses by licensed professionals of mental retardation or mental illness, including a psychiatric ward in a general hospital.

12f. Alien – Any person not a citizen or national of the United States.

Alien illegally or unlawfully in the United States - Aliens who are unlawfully in the United States are not in valid immigrant, nonimmigrant or parole status. The term includes any alien (a) who unlawfully entered the United States without inspection and authorization by an immigration officer and who has not been paroled into the United States under section 212(d)(5) of the Immigration and Nationality Act (INA); (b) who is a nonimmigrant and whose authorized period of stay has expired or who has violated the terms of the nonimmigrant category in which he or she was admitted; (c) paroled under INA section 212(d)(5) whose authorized period of parole has expired or whose parole status has been terminated; or (d) under an order of deportation, exclusion, or removal, or under an order to depart the United States voluntarily, whether or not he or she has left the United States.

12g. – (i) An alien (other than an alien lawfully admitted for permanent residence) who is a national of a country as to which the Secretary of State has made a determination that such country has repeatedly provided support for acts of international terrorism or, (ii) any individual (regardless of nationality) that acts for or on behalf of, or operates subject to the direction or control of, a government or official of the countries listed below.

State Sponsor of Terrorism	Designated Date
Syria	12-29-1979
Cuba	03-01-1982
Iran	01-19-1984
Sudan	08-12-1993

12h. Service in the Armed Forces – Indicate if the applicant has served in the Armed Forces

12i. Discharged under dishonorable conditions - Separation from the U.S. Armed Forces resulting from a dishonorable discharge or dismissal adjudged by a general court-martial. The term does not include any separation from the Armed Forces resulting from any other discharge, e.g. a bad conduct discharge.

12j. Terrorist organization - An organization (i) designated by the Secretary of State as a foreign terrorist organization (ii) otherwise designated by the Secretary of State in consultation with or upon the request of the Attorney General or the Secretary of Homeland Security as a terrorist organization; or (iii) that is a group of two or more individuals, whether organized or not, which engages in, or has a subgroup which engages in terrorist activity [as defined in 8 U.S.C. 1182 (a)(3)(B)]

Section IV:

By signing, the applicant certifies that the questions in Section III are true, correct and complete. Also, the applicant's signature gives consent to the U.S. Department of Justice to complete the SRA. The printed name must be legible. The signature date must be current (occurring within the last 90 days). Electronic signatures are not acceptable.

Section V:

By signing, the RO or ARO certifies that the completed FD-961 Form was reviewed for completeness, legibility, and that the certification questions have been reviewed and handled accordingly. Electronic signatures are not acceptable. Please include an email address for requests for additional or incomplete information.

Questions concerning completion of the FD-961 Form can be directed to BRAG at 304-625-4900.

Completion of Fingerprint Cards

The fingerprint card packet consists of two fingerprint cards, general instructions, fingerprint instructions, and a pre-addressed return envelope. The following fields should be completed on the fingerprint cards: residence, employer and address, name, aliases, citizenship, social security number, sex, race, height, weight, eye color, hair color, date of birth and place of birth. The applicant must have the two fingerprint cards printed by a local law enforcement agency. The individual or entity must arrange for this service. In most instances, law enforcement offices will charge a fee for this service. The two fingerprint cards and completed FD-961 Form must be submitted to the FBI as one package for the security risk assessment to be completed. The FBI may request a second set of prints to process in the event that the initial two fingerprint cards are rejected from the Integrated Automated Fingerprint Identification System for image quality.

PRIVACY ACT STATEMENT

Authority:

Collection of this information is authorized under Public Law 107-188; 18 U.S.C. § 175b; 28 U.S.C. § 534; 28 CFR § 0.85; 7 CFR Part 331; 9 CFR Part 121; 42 CFR Part 73.

Principal Purpose and Routine Uses

The information collected on this form will be used for the principal purpose of conducting security risk assessments for entities that possess, receive, use and/or transfer select agents and toxins, individuals who own or control an entity, individuals authorized to have access to select agents or toxins, and responsible officers. As part of this assessment, the collected data may also be used to assist in determining approval, denial, revocation or renewal of a certificate of registration issued by Department of Health and Human Services (HHS) or U.S. Department of Agriculture (USDA) for possession, use and transfer of select agents and toxins.

Additionally, information provided in all or part of this completed form may be disclosed to Department of Justice personnel who need the information in the performance of their duties and outside the Department of Justice to HHS and/or USDA for the purpose of making security risk assessments and other determinations relating to individuals, entities and responsible officers that have access to or possess, use, receive and/or transfer select agents and toxins; to federal, state, local, joint, tribal, foreign or international entities charged with the responsibility of investigating, prosecuting, and/or enforcing laws, regulations, rules, orders or contracts if any part of the information received, either on its face or in conjunction with other information, indicates a violation or potential violation of law, regulation, rule, order, or contract; to any law enforcement or intelligence authority or other federal, state or local entity with relevant jurisdiction where such information reveals a risk to human, animal and/or plant health or national security; to organizations or individuals, both public and private, if deemed necessary, in the sole discretion of the U.S. Department of Justice, to elicit information or cooperation from the recipient for use in assessing suitability to access, possess, use, receive or transfer select agents and toxins; and pursuant to the routine uses most recently published in the Federal Register for the FBI's Central Records System (Justice/FBI-002) and the FBI's Blanket Routine Uses (Justice/FBI-BRU).

Social Security Account Number

Your Social Security Account Number (SSAN) is requested under Public Law 107-188, 7 CFR Part 331, 9 CFR Part 121 and 42 CFR Part 73, which authorize the Attorney General to collect names and other identifying information in the security risk assessment process and to check criminal, immigration, national security and other electronic databases. Because other people may have the same name and birth date, your SSAN will be used to facilitate accurate identification and to help eliminate the possibility of misidentification of individuals for whom a security risk assessment or database check is being conducted.

Effects of Nondisclosure

Completion of this form and provision of your SSAN is voluntary. However, failure to provide the requested information may delay the timely processing of your security risk assessment.

PAPERWORK REDUCTION ACT NOTICE

The information required on this form is in accordance with the Paper Work Reduction Act of 1995. The purpose of this information is to assist the FBI in national security risk assessments for entities and individuals having access to selected toxins as required by the Public Health Security and Bioterrorism Preparedness Response Act of 2002.

The estimated average burden associated with this collection of information is 45 minutes, depending on circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Bioterrorism Security Risk Assessment Group Mod E-3, Criminal Justice Information Services Division, Federal Bureau of Investigation, 1000 Custer Hollow Road, Clarksburg, WV 26306.

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