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 D-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 emailed to BRAG at FD961@leo.gov. Please ensure that the photo is scanned according to the digital image requirements on page 4 of the FD-961 and as listed in the Instructions for Section IV. 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Please note that incomplete, expired (Rev. 04-01-2014 and earlier) or outdated forms (signature date exceeds 90 days) will not be processed.

Section I:

1. Provide the legal name of the entity.

2. Enter the entity application number supplied by APHIS or CDC (AGRXXXXXX or CDCXXXXXX).

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

Section II:

4. 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.

5a. Applicant's last name (last name suffix, e.g. Jr. or III). The name provided in blocks 5a-5c should be identical to that listed on the APHIS/CDC Form 1.

5b. Applicant’s first name.

5c. Applicant’s middle name.

5d. List all Aliases/Maiden names (Last, First, Middle).

6. Provide date of birth.

7. Social security number.

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

8a. Indicate if applicant has any previous states of residence (states in which the applicant has resided since the age of 18).

8b. 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.

9. Applicant’s home phone number(s) (xxx-xxx-xxxx).

10. Applicant’s cell phone number(s) (xxx-xxx-xxxx).

11. Applicant’s email address(es).

12. Applicant’s sex (male or female).

13. Indicate applicant’s ethnicity (choose Hispanic or Latino or Not Hispanic or Latino).

Ethnic Categories (“Hispanic or Latino” and “Not Hispanic or Latino”)

• Hispanic or Latino: An indication that the person traces his or her origin or descent to Mexico, Puerto Rico, Cuba, Central and South America, and other Spanish cultures, regardless of race.

14. Indicate applicant’s race (mark all races that apply) using the decision chart below:

Racial Categories

• American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains cultural identification through tribal affiliation or community attachment.

• Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This area includes, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• Black or African American: A person having origins in any of the black racial groups of Africa.

• Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

15. 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.

16. 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 – 12i: 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 fled from any state to avoid prosecution for a felony or a misdemeanor; or a person who leaves the state to avoid giving testimony in any criminal proceeding; or a person who knows that misdemeanor or felony charges are pending against such an individual and who leaves the state of prosecution and does not appear before the prosecuting tribunal. Fugitives from justice do not include individuals who are charged with crimes and there is no evidence that they left the state. A person is not a fugitive from justice merely because he or she has an outstanding civil traffic citation.

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
Iran	01-19-1984
Sudan	08-12-1993

12h. 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.

12i. 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:

Attach a current photo of yourself and write your name and UIN on the back of the photo.

You must provide one photo with your application. To avoid processing delays, we recommend you use a professional photo service. Your photo must be:

• In color

• Printed on matte or glossy quality paper

• 2 x 2 inches (51 x 51 mm) in size

• Sized such that the head is between 1 inch and 1 3/8 inches (between 25 and 35 mm) from the bottom of the chin to the top of the head

• Taken within the last 6 months to reflect your current appearance

• Taken in front of a plain white or off-white background

• Taken in full-face view directly facing the camera

• Taken with a neutral facial expression (preferred) or a natural smile, and both eyes open

While we recommend you use a professional passport service to ensure your photo meets all the requirements, you may take the photo yourself. Hand-held self portraits are not acceptable. Photos must not be digitally enhanced or altered to change your appearance in any way. If you take the photo yourself with a digital camera, the digital image must adhere to the following specifications:

Dimensions: The image dimensions must be in a square aspect ratio (the height must be equal to the width). Minimum acceptable dimensions are 600 x 600 pixels. Maximum acceptable dimensions are 1200 x 1200 pixels.

Color: The image must be in color in sRGB color space which is the common output for most digital cameras.

If you want to scan an existing photo, in addition to the digital image requirements, your photo must be:

• 2 x 2 inches (51 x 51 mm)

Scanned at a resolution of 300 pixels per inch (12 pixels per millimeter)

Section V:

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:

The information collected on this form will be used for the principal purpose of conducting a security risk assessment to determine if you may possess, receive, access, use and/or transfer select agents and toxins. As part of this assessment, the collected information 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.

The FBI's acquisition, preservation, and exchange of fingerprints and associated information are generally authorized under 28 U.S.C. 534. The civil fingerprint records contained in Next Generation Identification (NGI) are only available to Department of Justice (DOJ) components when there is a need for the information in order to perform official duties, pursuant to 28 U.S.C. § 534 and 5 U.S.C.§ 552a(b)(1). Civil fingerprint data within NGI will also be shared with federal, local, state, and tribal agencies as permitted by applicable Federal and State statutes, Federal and State executive orders, or regulation or order by the Attorney General. Information is shared with authorized noncriminal justice agencies and entities for employment suitability checks, permits, identity verification, and licensing in accordance with applicable laws, regulations and policies. Providing your fingerprints and associated information/biometrics is voluntary; however: failure to do so may affect completion or approval of your application.

Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's NGI system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses:

During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system, the FBI’s Central Records System, and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, access clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

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. Completion of this form and provision of your SSAN is voluntary. However, failure to provide the requested information may delay or result in the denial 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.

Section VI:

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). Digital and electronic signatures are not acceptable. The applicant is required to initial each page of the FD-961 at the bottom where indicated.

Section VII:

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. Digital and electronic signatures are not acceptable. Please include an email address for requests for additional or incomplete information. The RO or ARO must also initial each page of the FD-961 at the bottom where indicated.

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.

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