TENNESSEE VALLEY AUTHORITY
NUCLEAR POWER GROUP
PERSONAL HISTORY QUESTIONNAIRE (PHQ)
• NRC requirements and TVA procedures require the reporting of all legal actions
prior to and while maintaining unescorted access to the nuclear facilities
• Any misrepresentation, deliberate misstatement, falsification or willful omission
may result in denial of unescorted access which may result in lengthy (five-year)
to permanent exclusion from work at any US nuclear power plant
• You may also be subject to a fine and/or criminal prosecution for deliberate misconduct
under federal regulations
• If you have questions ASK
• If you are unsure if they need to be listed, LIST
Confirm the previously entered fields
**NOTE: If your last unescorted access ended less than 31 days ago, or if you currently
hold unescorted access at another nuclear power plant, please see Plant Access for
Date you last held access:
Plant where you last held access:
All information provided will be treated as PERSONAL - CONFIDENTIAL and observed only by
persons with an authorized NEED TO KNOW, or in accordance with applicable law.
In order to meet the requirements of the Nuclear Regulatory Commission (NRC) the Tennessee Valley Authority Nuclear Power Group (TVANPG), to which you are applying for unescorted access authorization (UAA), unescorted access (UA) and/or access to safeguards information requires that you consent to undergo a background screening process. The purpose of the screening process is to determine your trustworthiness and reliability to work within the protected and vital areas of a nuclear power plant (NPP). Information from this form will be used to conduct a background investigation for access authorization purposes as required by the NRC.
You must provide all information requested in a complete and accurate manner.
Your signature on the document is your certification that the information you have provided is complete and correct. Providing deliberate or willful misleading statements to any NPP with the intent to gain access is a violation of Federal regulations. Any misrepresentation, deliberate misstatement, falsification or willful omission may constitute cause for denial or revocation of UAA/UA and/or access to safeguards information. Failure to report and list reasons for any previous suspension, revocation or denial of UAA/UA and/or access to safeguards information at a NPP or other entity subject to either the NRC access authorization, FFD or Safeguards Information regulations may be sufficient cause for denial or revocation of UAA/UA and/or access to safeguards information. If such an instance is detected the plant is required to advise the NRC. The NRC may investigate you and, if appropriate, criminal and civil sanctions may be imposed against you if deemed material by the NRC. When such instances have previously occurred, the result has been a lengthy (five-year) or permanent exclusion from work at nuclear power plants in the United States.
The facts concerning your criminal history or fitness-for-duty record may be subject to interpretation due to varying categorizations of similar offenses between states. It is therefore required that you disclose all information that has any potential for being considered as derogatory to minimize the likelihood of discrepancies between the information you provided and that obtained from other sources. All information requested is needed for the purpose established by the NRC regulation or Orders. Results of the investigation will be available as specified in your signed Consent form, to entities authorized by the NRC pursuant to UAA/UA, FFD and Safeguards Information regulations. In some of the sections of the Personal History Questionnaire (PHQ) you are required to provide your personal information; in other sections you will be required to acknowledge that you understand certain on-going requirements or personal responsibilities. The information requested may include any or all of the following topics: verification of identify, self-disclosure data, employment/unemployment history (including military service and/or education in lieu of employment), criminal history, credit history, character references, residences, and fitness-for-duty history. When not in use, your written information is stored in a secure environment, which may include being electronically placed in a secure database, to prevent unauthorized disclosure of personal information.
Information from this form will be used to conduct a background investigation for access authorization purposes as required by the Nuclear Regulatory Commission (NRC). The information you are asked to provide is specific, explicit personal history information including: work history and locations, personal references, criminal history, and psychological and fitness-for-duty history. You must
provide all information requested in completing this document. No information is requested that is not needed for the purpose established by regulation - to evaluate your trustworthiness and reliability for UA at a NPP.
The licensee requesting the completion of this document may require your Social Security Number (SSN), the last 4 digits of your SSN and/or provide you with a protected unique identification number or password lined to you for use on this form. The NRC requires the verification of true identity and you will be required to disclose your SSN that will be maintained for the same period as your personal information contained on this PHQ.
YOU ARE REQUIRED TO REPORT ANY LEGAL ACTIONS BETWEEN SIGNING THIS PHQ AND BEING GRANTED UNESCORTED ACCESS AUTHORIZATION/UNESCORTED ACCESS.
Unless otherwise instructed, you are required to complete all portions of this PHQ to be considered for UAA/UA at a TVA site. Please type or print (use black ink) the specific answers to all questions and requests for information. Single line out and initial mistakes. Write "None" or "N/A" when the question is not applicable. Some questions are followed by requests for additional data. Enter all dates in the format two digit month, two digit day and four digit year (MM/DD/YYYY)
. When asked Yes/No, circle or check
the applicable response. Attach properly cross-referenced continuation sheets to the PHQ if the length of an explanation exceeds the space provided. After completing the PHQ, review the questionnaire to ensure there are no omissions and your printed name and social security number are included on each page. Number each page sequentially.
Have you ever applied for or been granted UAA/UA at a Nuclear Power Plant (NPP)?
Have you ever applied for or been granted access to a NPP under construction?
Have you ever applied for or been granted access to Safeguards Information at a NPP or NPP under construction?
Note: Occasionally, the NRC takes enforcement action against individuals working under the NRC’s jurisdiction. When the NRC loses reasonable assurance that an individual is willing or able to comply with NRC requirements, typically demonstrated by deliberate misconduct, the agency may issue an enforcement order that includes a prohibition against all or some forms of NRC licensed activities. In addition, the NRC may engage in alternative dispute resolution with an individual who the NRC believes has willfully violated NRC requirements. Through alternative dispute resolution, the NRC may issue a confirmatory order that includes an agreed-upon period of prohibition from all or some types of NRC-licensed activities. In less significant cases, the agency may issue a notice of violation to an individual.
Have you ever been issued an NRC Escalated Enforcement Action?
If yes, please provide details.
PERSONAL DATA - RESIDENCES
If you have NOT held Unescorted Access at a nuclear plant within the last 3 years, list all residences, excluding your permanent residence, where you have lived for more than 30 days in the past seven (7) years.
If you HAVE held Unescorted Access within the last 3 years, list all residences, excluding your permanent residence, where you have lived for more than 30 days since you last held unescorted access.
Residence Step 1: Fill out the following form.
PERSONAL DATA-FOREIGN TRAVEL
In the past 5 years, since your 18th BIRTHDAY, or since your last favorable access whichever period is shorter, have you traveled to any foreign country?
Do not include travel when in the service of any US government agency (e.g., US Military, State Department, etc.)
Note: IF a single trip encompassed multiple countries, please explain on continuation sheet.
List three individuals who are available for immediate contact and who can comment on your character and reputation and who have had recent (within the past 6 months) contact with you.
References cannot be a known close relative (i.e., spouse, parent, sibling or child) and cannot be living in your household at the time you complete this application.
They may be friends, neighbors, or other persons with whom you have frequent personal and/or business relationships.
Provide home address (actual street address), not post office box numbers. List telephone numbers where each reference can be reached.
Closest relative not living with you:
CREDIT HISTORY - (Not applicable if you have held
Unescorted Access at a nuclear plant within the last 365 days.)
In the past seven (7) years, have you had any of the following:
If you responded yes to any of the above, provide the reason or circumstances for these difficulties:
Note: If you have placed a security freeze on your credit file, the credit file must be unfrozen in order for the required credit check to be completed. Changing the status of your credit file is your responsibility.
Your credit will be checked through a national credit agency. If you do not have an established credit history, list a source of credit such as a bank or department store charge account or any personal sources of credit. (Examples: local gas station, company sales representative, etc.)
EDUCATION HISTORY AS EMPLOYMENT
In the past 5 years, since your 18th birthday or since your last favorable access (whichever is shorter), were you enrolled, with education as your primary activity, in an educational institution in lieu of employment?
If Yes, complete this section for each enrollment.
If claiming any education, a copy of an official educational institution transcript must be provided.
Were you subject to any disciplinary action at any of the above listed educational institutes?
If yes, provide details:
MILITARY SERVICE AS EMPLOYMENT
Did you serve in the military, as your primary job, within the last three (3) years, since your 18th birthday or since your last favorable access (whichever is shorter)?
, complete this section for each period of service.
Do you have the DD Form 214 you received upon discharge?
If Yes, present the Original DD214 with this PHQ, a copy will be retained and the original returned after authentication.
I have read, understand and acknowledge the purpose of this personal history questionnaire (PHQ) and that I have furnished the requested information under the stated conditions. I have read and understand the information concerning NRC required fingerprints and criminal history record.
I have been advised that any falsification or willful omission of information may be a violation of Nuclear Regulatory Commission (NRC) regulations. The facts concerning my criminal history or fitness for duty (FFD) record may be subject to interpretation because different states may categorize the same offenses differently. It is therefore suggested that I disclose all potentially derogatory information and reduce the likelihood of discrepancies between the information I have provided and that obtained from other sources. Failure to list reasons for any previous suspension, revocation or denial of Unescorted Access (UA) to a nuclear facility or other entity subject to either NRC or FFD regulation may be sufficient cause for denial of UAA/UA and/or civil penalties from the NRC.
The information that I have provided in this PHQ is correct and complete to the best of my knowledge and belief. I make this statement with knowledge that any false or misleading statement or omission of any fact may be sufficient cause for denial of UAA/UA and/or safeguards information access. I understand that the information I have provided in this form will be verified by authorized background investigators and will be used only for access authorization purposes, or otherwise in accordance with applicable law.
I understand that if I am certified UAA or granted UA, it is my responsibility, under the Behavioral Observation Program (BOP), to report any legal action to my supervisor in accordance with Tennessee Valley Authority Nuclear Power Group (TVANPG) procedures. I must also report any legal actions from the time I complete this PHQ until I am certified UAA or granted UA. An evaluation will be made regarding the impact of the legal action on my UAA/UA. The determination of what constitutes a legal action is a matter of state law but, in general, the term legal action means:
A formal action taken by a law enforcement authority or court of law, including being held, detained, taken into custody, charged, arrested, indicted, fined, forfeited bond, cited, or convicted for a violation of any law, regulation or ordinance this includes felony, misdemeanor, serious traffic offenses, serious civil charges or military charges but does not include minor misdemeanors such as parking tickets or minor civil actions such as zoning violations or minor traffic violations such as moving violations when the individual was not physically taken into custody, and includes the mandated implementation of a plan for treatment or mitigation in order to avoid a permanent record of an arrest or convictions in response to the following:
(1) the use, sale or possession of illegal drugs (including controlled substances determined to be illegal under federal law, such as marijuana, but deemed legal under a state law),
(2) the abuse of legal drugs or alcohol,
(3) or the refusal to take a drug or alcohol test.
I have been advised of my right to request to review the information developed to assure its accuracy and completeness. I understand that the information collected during the conduct of the background investigation will be retained and must be made available to any other nuclear power plant where I may request access. It will only be used in determining my eligibility to be certified UAA, granted UA and/or granted access to safeguards information. This information will be retained for a period of time after the last termination of my UAA/UA or Safeguards Information Access or denial of my UAA/UA and/or denial of my access to safeguards information.
I hereby acknowledge that in order for me to work within the protected and/or vital areas of a Tennessee Valley Authority Nuclear Power Group (TVANPG) site, I am subject to a background investigation to determine my trustworthiness and reliability, and consent to such an investigation by TVANPG, its investigative agents, or its approved contractors/vendors (C/Vs). This investigation may include, but is not limited to, a verification of identity, self-disclosure data, employment/unemployment history (including military service and/or education in lieu of employment), criminal history, credit history, character references, residences, and fitness for duty history, as well as a medical/psychological evaluation. This information may be obtained through contact with federal, state, and local governmental agencies, educational institutions, previous and current employers, institutions and individuals, and others, whether or not specifically mentioned herein, as may have records or personal knowledge relating to me or my activities. I authorize TVA, its investigative agents, or its approved C/Vs to release all information obtained concerning me to any nuclear facility or the U.S. Nuclear Regulatory Commission (NRC) for their determination of my eligibility for unescorted access.
I acknowledge the information collected/transferred concerning me pursuant to this process is considered confidential and is protected from unauthorized disclosure. Disclosure is authorized under the following conditions: other licensees, C/Vs or their authorized representatives seeking the information for UAA determinations; NRC representatives; appropriate law enforcement officials under court order; myself or my representative, who I have designated in writing; those licensee representatives or C/Vs who have a need to have access to the information in performing assigned duties including audits of licensee, contractor, or vendor programs, except where specifically excluded by regulation; persons deciding matters on review or appeal; or, other persons pursuant to court order or otherwise in accordance with applicable law. These will be reviewed on a case-by-case basis. I acknowledge that the results of this investigation will be maintained by TVANPG or its C/Vs through my period of employment and for at least five years following termination of my unescorted access.
I acknowledge that, upon my proper request, I have the right to review the information collected during the background investigation process and maintained at the TVA Nuclear Access Services office to ensure its accuracy and completeness.
I hereby authorize any person, agency, organization, or institution to release to TVANPG, its investigative agents, or approved C/Vs such information as may be requested about me, based on a determination that the information is necessary or appropriate in connection with investigating me for unescorted access. This authorization specifically includes release of any and all information by my present and previous employers, law enforcement agencies, educational institutions, teachers, professors, landlords, friends, family members, and others, whether or not specifically mentioned herein. The information covered by this authorization may include, but is not limited to, academic, residential, achievement, performance, attendance, disciplinary, financial, arrest and conviction records, and records relating to my moral character and mental stability.
I hereby waive any and all claims against the United States, TVA, their employees, their C/Vs, their authorized investigative agents, TVA’s approved C/Vs, and any person, agency, organization, or institution (including record custodians) which provides information to TVA, TVA’s employees, or authorized investigative agents, for loss or damage of whatever kind or nature which may at any time result on account of compliance, or any attempts to comply, with this authorization.
I acknowledge that disclosure of information is voluntary and that I may withdraw my authorization/consent at any point; but, in doing so, I will not be eligible for unescorted access.
I acknowledge my responsibility to report any legal actions, including legal actions which occur between signing this form and being granted UAA/unescorted access, to Nuclear Access Services Plant Access or Corporate Nuclear Access Services, as well as my supervisor, the next business day and prior to entry into the protected area after any such legal action.
I have read and understand all of the terms contained in this Authorization, Consent, and Acknowledgment.
Subsection (e) (3) of 5 U.S.C. § 552a (Section 3 of the Privacy Act)) requires that TVA inform you of its authority to request information and the uses which TVA may make of the information requested. That subsection further requires TVA to inform you of the effects of not providing any or all the requested information.
TVA’s authority to request the information you will provide is derived from the TVA Act (16 U.S.C. §§ 831-831 ee), Executive Order No. 10450, the Atomic Energy Act of 1954, as amended, and a number of other statutes and Presidential Executive orders. Information provided on this form may be furnished to people, agencies, organizations, or institutions in order to obtain information regarding you in connection with an investigation to determine: (1) fitness for TVA employment; (2) clearance to perform services for TVA under personal services, consultant, or other contracts; or (3) security clearance or clearance for access to TVA installations.
Furnishing the requested information is voluntary; however, failure to provide all or part of the information may result in a lack of further consideration for employment, clearance or access, or in the termination of your employment.
Information provided on this form is normally used only to determine fitness for employment or security clearance for access to TVA installations. Information obtained on this form may be furnished to third parties as authorized by law. For example, should a dispute arise or a congressional inquiry be made regarding TVA employment practices, the information may be made available outside of TVA in the course of that dispute or inquiry. Further, information provided may be provided to another federal agency if relevant to a decision to be made by that agency. In addition, information on this form may be made available to law enforcement agencies in the exercise of their duties, or to a prospective employer or TVA contractor upon proper request.
DISCLOSURE AND AUTHORIZATION STATEMENT
For the purpose of evaluating my application for or maintenance of nuclear power plant access authorization, I understand TVA or its contractors / vendors may obtain or have prepared a consumer report or investigative consumer report concerning my prior employment, military record, education, credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, criminal background record, or mode of living.
I understand that upon written request to TVA, I will be informed whether an investigative consumer report was requested, and given full information as to the nature and scope of this investigation. I understand that an investigative consumer report is a report in which information concerning my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, or associates with whom I am acquainted.
By signing below, I am authorizing TVA, its contractors / vendors or its investigative agents to obtain a consumer or investigative consumer report on me as part of the screening process for access authorization. During the period in which I retain access authorization, I further authorize the obtaining of additional consumer or investigative consumer reports on me to evaluate my trustworthiness and reliability for purposes of determining and maintaining continued unescorted access authorization.
By my signature below, I also acknowledge that I have been provided a summary of my rights under the Federal Fair Credit Reporting Act (attached copy prepared by the Consumer Financial Protection Bureau).
I have read and understand this Consent and authorize TVA and/or its contractors/vendors to take such actions as are described herein.
The Tennessee Valley Authority (TVA) has my consent to:
Collect personal information about me in order to verify the information’s accuracy;
Conduct a background investigation (BI) in accordance with U. S. Nuclear Regulatory Commission (NRC) regulations to verify information I have provided on a Personal History Questionnaire and other information, as necessary;
Take my fingerprints and associated biographic identifiers to conduct a check of the criminal history information records contained within the Federal Bureau of Investigation’s (FBI’s) Integrated Automated Fingerprint Information System (IAFIS) and the National Crime Information Center (NCIC) and retain the submitted information in the FBI’s collection of fingerprints and submitted information where it will be subject to comparisons against other submissions including latent fingerprints received by the FBI.
Retain personal information provided for investigation; and
Transfer information from other licensees, as necessary, including: (i) information pertaining to the denial of unescorted access authorization (UAA) or unescorted Access (UA), or denial of access to a nuclear power plant under construction, to determine whether to certify UAA, grant UA to a U. S. NRC-licensed facility and to allow me to maintain such access; or (ii) information pertaining to denial of access to Safeguards Information.
With the exception of criminal history record information (CHRI) collected under 10CFR 73.57, the information collected will only be used for the purposes of determining UAA/ UA in accordance with 10 CFR 73.56,
Personnel Access Authorization Requirements for Nuclear Power Plants
, separate fitness-for-duty (FFD) authorization in accordance with 10 CFR Part 26,
Fitness for Duty Programs
, access to a nuclear power plant under construction, and/or access to Safeguards Information in accordance with 10 CFR 73.21, 73.22 or 73.23,
Protection of Safeguards Information
, unless I provide a separate release to the licensee for another purpose. CHRI may only be used for the purposes of determining whether a person is suitable for unescorted access to a nuclear power plant or for access to Safeguards Information, and may not be used for any other purpose. I understand that evidence of criminal conduct detected during the conduct of a BI must be reported to the appropriate law enforcement agency by the licensee or contractor/vendor (C/V). I authorize the use of signed copies of this consent to be used in place of an originally signed consent document. The NRC requires that the information collected be used in determining that an individual is trustworthy, reliable, and fit for duty prior to certifying UAA, granting UA, while maintaining UAA/UA; granting access to a nuclear power plant under construction; and before granting access to safeguards information. The results of this determination must be available to other NRC licensed facilities.
Any of the following actions related to the providing and sharing of personal information is sufficient cause for denial or unfavorable termination of UAA/UA, access to a nuclear power plant under construction, and/or access to Safeguards Information:
Refusal to provide written consent for the background investigation and/or suitable inquiry;
Refusal to provide information or the falsification of any personal information required under 10 CFR 73.56,
Personnel Access Authorization Requirements for Nuclear Power Plants, 10 CFR 26,
Fitness-for-Duty Programs, and/or 10 CFR 73.21, 73.22 or 73.23,
Protection of Safeguards Information, including, but not limited to, the failure to report any previous denial or unfavorable termination of authorization;
Refusal to provide written consent for the sharing of personal information with other licensees or other entities required under 10 CFR 73.56,
Personnel Access Authorization Requirements for Nuclear Power Plants, 10 CFR 26,
Fitness-for-Duty Programs, and/or 10 CFR 73.21, 73.22 or 73.23,
Protection of Safeguards Information; and
Failure to report any legal actions in accordance with 10 CFR 73.56(g).
I understand that the domestic commercial nuclear industry uses a computerized, restricted-access data system, the Personnel Access Data System (PADS), to share information necessary to process applications of workers for UAA/UA to nuclear facilities, access to nuclear facilities, access to a nuclear power plant under construction, and/or access to Safeguards Information. I further understand that this system is intended to permit nuclear facility licensees and their accepted contractors/vendors to meet regulatory requirements mandating that certain information be available to any facility licensee by retaining certain access information in a central computer database.
I understand that the information may be transferred, electronically or otherwise, to other licensees and contractor/vendors or the agents of each. This information will include, but is not limited to:
Name and Social Security Number;
Place of birth and physical characteristics;
Dates when any of the following are completed: background investigation, psychological evaluation, fitness-for-duty testing, suitable inquiry checks;
Dates when UAA/UA, access to a nuclear power plant construction site, and/or access to Safeguards Information has been authorized or terminated;
Date of any denial of UAA/UA, access to a nuclear power plant under construction, and/or access to Safeguards Information and the company holding the relevant information;
Dates associated with FFD testing (pre-access, post–event, for cause and follow-up) and treatment;
Annual radiation exposure history;
Respiratory equipment qualification/fit testing;
Medical qualification for respirator use;
Data concerning training required for UAA/UA, access to a nuclear power plant construction site, access to Safeguards Information and work qualification; and
Direction to seek additional information directly from another licensee.
I authorize any individual, organization, institution, or entity that now has, or obtains in the future, access-related information about me (examples of which are provided in the above paragraph), whether or not such information is included in the PADS database, to release any such information in order to perform the investigation and evaluation required for UAA/UA, access to a nuclear power plant construction site and/or access to Safeguards Information.
I understand that information contained within an FBI criminal history record will be restricted to the NRC, nuclear licensee facilities regulated by the NRC, and myself, and that the criminal history information will not be released to contractor/vendors or their agents.
I authorize the entry into the PADS computer database of any information collected for the purpose of processing my application for, or continued maintenance of, UAA/UA, access to a nuclear power plant construction site, and/or access to Safeguards Information. I authorize the transfer of such information, electronically or otherwise, to other NRC nuclear facility licensees and contractors/vendors. I authorize such licensees and contractors/vendors to use the database information for the purpose of determining my eligibility for UAA/UA, for access to a nuclear power plant construction site, and/or for access to Safeguards Information.
I understand that information obtained pursuant to this Consent shall be treated as confidential. The release of access-related information about me shall be limited to regulatory agencies and such employees of NRC facility licensees and their contractors/vendors who have been designated as having a "need to know"” the information in order to do their jobs. The following is a listing of individuals that may access information without my consent in order to perform their official duties:
Myself or my representative, when I have designated the representative in writing for specified UAA/UA, nuclear power plant construction site access, safeguards information access and/or FFD matters;
Assigned Medical Review Officers (MROs) and MRO staff;
Appropriate law enforcement officials under court order;
Licensee, contractor/vendor, or their agents who have a need to have access to the information to perform their assigned duties under the UAA/UA, nuclear power plant construction site access, safeguards information access, and/or FFD programs, including determinations of fitness, access authorization or FFD program audits, and some human resources functions;
Presiding officer in a judicial or administrative proceeding that is initiated by the subject individual;
Persons deciding matters under access authorization or FFD program appeal process; and
Other persons pursuant to court order.
I understand that all information about me in the database will be maintained as securely as reasonably practicable for a period of at least 5 years after UAA/UA, access to a nuclear power plant construction site, and/or access to Safeguards Information is last terminated. The types of records maintained include documentation collected during the administration of the access authorization and FFD programs. All documents pertaining to a 5 year or permanent denial of UAA/UA required by 10 CFR 26 will be retained by a licensee making the denial or unfavorable termination of UAA/UA for 40 years or the NRC determines that the records are no longer needed. The records of FFD training and examinations conducted under 10 CFR 26 and 10 CFR 73.21, 73.22, or 73.23 will be maintained for at least 3 years. Records identified are normally maintained at the TVA Nuclear Access Services office.
I understand that if I determine that in accordance with 28 CFR 16.34,
Procedure to obtain change, correction or updating of identification records
—If, after reviewing my identification record, I believe that it is incorrect or incomplete in any respect and wish changes, corrections or updating of the alleged deficiency, I may make application directly to the agency which contributed the questioned information. I may also direct my challenge as to the accuracy or completeness of any entry on your record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency.
I understand that I have a right to review information collected and maintained by TVA to assure it is accurate and complete and to correct any inaccurate or incomplete information. I understand that, upon my written request to TVA, and at no cost to me, I will be provided, within 10 business days, with a printed copy of the information about me which is recorded in the database. If, after my review of such information, I can show that any of the information is incorrect or incomplete, such information will be corrected and/or completed as soon as is reasonably practical.
I understand that at any time and upon written notice to TVA, I may withdraw this Consent, but this will also constitute a withdrawal of my request for access. I understand that any processing activities that were initiated before receipt of my withdrawal of consent shall continue and the resulting information will be retained in the database. No new inquiries shall be initiated after receipt of my withdrawal of consent. Thereafter, PADS participants are not permitted to retrieve information from the database other than my name, date of birth, identification number, and the fact that my consent has been withdrawn, unless I provide a currently valid Consent or the information sought is required by NRC regulation.
I hereby release TVA, other PADS participants, NEI, and the officers, employees, representatives, agents, and records custodians of each as well as the officers, employees, representatives, agents, and records custodians of any entity or individual supplying or using such information from any and all liability based on their authorized receipt, disclosure, or use of the information obtained pursuant to this Consent and to determine my eligibility for UAA/UA to nuclear facilities, access to a nuclear power plant under construction, and/or access to Safeguards Information.
I understand that this Consent is not intended to and does not affect any right or responsibility that I, my employer (if not TVA), or TVA may have under Section 211 of the Energy Reorganization Act of 1974, as amended. I further understand that nothing herein (1) affects my right or my responsibility to bring potential safety concerns to my employer (if not TVA), TVA, or the NRC; or (2) prohibits me from participating in any proceeding or investigation regarding such a potential safety concern.
I have read and understand this Consent and authorize TVA to take such actions as are described herein or specified by PADS procedures. While I understand that UAA/UA, access to a nuclear power plant construction site and/or access to Safeguards Information is dependent upon my accepting the regulatory requirements of this program, the statements made by me in this Consent and my decision to sign this Consent are voluntary. The statements were not induced by any promise nor have I been subjected to any threat, duress or coercion to sign this Consent.
The Nuclear Regulatory Commission requires that the company investigate your previous employment history and make inquiries of employers to determine whether or not there are any fitness for duty (FFD) concerns that must be explored and evaluated prior to certifying UAA or granting UA and/or granting safeguards information access.
Answer each question by checking either Yes or No as it pertains to you. For each Yes answer include the specific type of issue, duration and resolution, including, but not limited to the reason for an unfavorable termination or denial of UAA/UA. Details may include, but are not limited to, date, name and location of the employer or potential employer involved (to whom you applied for employment), nature of the violation, any hearing, penalty imposed or other disposition.
- violated a licensee or employer’s fitness-for-duty policy?
- been denied or had unescorted access authorization terminated unfavorably at any place of employment or at any nuclear power plant for any reason including fitness for duty policy violation or been unfavorably terminated from any employment for a fitness-for-duty reason?
- used, sold, or possessed illegal drugs (including controlled substances determined to be illegal under federal law, such as marijuana, but deemed legal under a state law)?
- abused legal drugs or alcohol?
- ever subverted or attempted to subvert a drug or alcohol testing program?
- refused to take a drug or alcohol test?
- been subject to a plan (except self-referral) for treating substance abuse?
- been subject to a law enforcement authority or court of law action for alcohol or drug use related to any of the following:
- The use, sale or possession of illegal drugs (including controlled substances determined to be illegal under federal law, such as marijuana, but deemed legal under a state law)?
- The abuse of legal drugs or alcohol?
- The refusal to take a drug or alcohol test?
- been subject to employment action taken for alcohol or drug abuse involving any of the following:
- A change in job responsibilities or removal from a job?
- Mandated implementation of a plan for substance abuse treatment in order to avoid a change in or removal from a job?
- Are you currently in a fitness-for-duty follow-up testing program?
Explain any "YES" answers , including date(s), location(s), and description of incident(s):
Providing false or deliberate misleading statements or omission of facts may be sufficient grounds for denial of unescorted access.
If you were fingerprinted, report the occurrence. If you currently have any criminal charges pending, report the charge.
You must list felony, misdemeanor, traffic or military criminal history to include court martial or non-judicial punishment including guilty pleas and
"nolo contendere" (meaning no contest); any suspended sentences, pretrial diversions, dismissals,
"nolle prosequi" (meaning not prosecuted). (You may omit non-injury traffic, parking offenses of less than $200 or minor civil actions such as zoning violations, when you were not physically taken into custody, but you
must include any alcohol/drug-related traffic offenses regardless of amount of fine.)
• If you have questions ASK
• If you are unsure if they need to be listed, LIST
- Been held, detained, taken into custody, charged, arrested, indicted, fined, forfeited bond, cited, or convicted for a violation of any law, regulation or ordinance (e.g., felony, misdemeanor, traffic or military criminal history, etc.) or do you now have such a case pending?
- Been charged, arrested or convicted of an alcohol or a controlled substance related offense, which includes: driving under the influence / while intoxicated (DUI / DWI), or have such a case pending?
- Been charged, arrested or convicted of an infraction of the law for which you were fined more than $200?
- Failed to appear in court for any offense(s)?
- Are you currently under indictment, on probation, parole, work release, or subject to any other control of a court (including restraining orders, orders of protection)?
If you answered Yes to any question above, list all occurrences below and provide specific details in the space provided on the next page. Add continuation pages as necessary.
The Nuclear Regulatory Commission requires that individuals with UAA/UA at Nuclear Power Plants report Legal Actions. A legal action will be judged based upon its potential to impact upon your trustworthiness. This is part of the Behavioral Observation Program. You must also report any legal actions from the time you complete this PHQ until granted UAA. Such legal actions will be considered in determining your reliability and trustworthiness and TVA’s decision whether to grant or maintain your Unescorted Access.
FINGERPRINT INFORMATION FOR FBI CRIMINAL HISTORY
The Nuclear Regulatory Commission regulation (10 CFR § 73.57) which implements Public Law 99-399
"Omnibus Diplomatic Security And Anti-Terrorism Act Of 1986" requires licensees to take the fingerprints of persons seeking unescorted access to nuclear power facilities or access to safeguards information and submit those prints to the FBI requesting criminal history checks.
In accordance with 28 CFR 16.34,
Procedure to obtain change, correction or updating of identification records—If, after reviewing your identification record, you believe that it is incorrect or incomplete in any respect and wish changes, corrections or updating of the alleged deficiency, you should make application directly to the agency which contributed the questioned information. You may also direct your challenge as to the accuracy or completeness of any entry on your record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency.
Your criminal record or personal information collected and maintained as a result of the fingerprints may not be disclosed to persons other than yourself, your authorized representative, or to those who have a need to know the information in performing assigned duties in the process of granting or denying unescorted access to the nuclear power facility or access to safeguards information. The information obtained from a criminal history record check will be made available to any other NRC licensee pursuant to an access clearance for you at another facility.
In accordance with 28 CFR 16.32, Procedure to obtain an identification record, you may obtain a copy thereof by submitting a written request via the U.S. mails directly to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. Such request must be accompanied by satisfactory proof of identity, which shall consist of name, date and place of birth and a set of rolled-inked fingerprint impressions placed upon fingerprint cards or forms commonly utilized for applicant or law enforcement purposes by law enforcement agencies.
Criminal history information obtained through the FBI may also be made available for examination by authorized representatives of the NRC in the course of their duties to determine compliance with regulations and laws. The criminal history record information will be retained as required by regulation after UAA/UA to the nuclear power facility or to safeguards information has been denied or terminated.
I have the following additional comments concerning criminal history:
Individuals applying for, certified for, granted or maintaining Unescorted Access Authorization (UAA), or Unescorted Access (UA), or Fitness-for-Duty Authorization (FFDA) at nuclear power plants must report legal actions from the time the individual signs the Personal History Questionnaire (PHQ) up to and including the time that the individual UAA/UA/FFDA is terminated. Legal actions will be judged based upon the potential to impact upon your trustworthiness. This is part of the Behavioral Observation Program (BOP).
To comply with regulatory requirements, you are required to report ANY legal action (you may omit non-injury traffic or parking offenses of less than $200 but you
must include any alcohol/drug-related traffic offenses regardless of amount of fine
) in writing, to Nuclear Access Services Plant Access or Nuclear Access Services Corporate and your supervisor no later than the next business day and prior to entry into the protected area after the legal action occurred. You must also report any legal actions from the time you complete this PHQ until granted Unescorted Access. You are also required to report any changes in the status of any legal action by the next business day and prior to entry into the protected area (i.e., changes in court date, charges dropped, arrest resulting in conviction, placed on probation, parole, work release, or subject to any other control of the court.)
A legal action is defined as:
Failure to report a legal action as required may result in denial, suspension, revocation, or withdrawal of UAA/UA or FFDA, and disciplinary action up to and including discharge.
A formal action taken by a law enforcement authority or court of law, including being held, detained, taken into custody, charged, arrested, indicted, fined, forfeited bond, cited, or convicted for a violation of any law, regulation or ordinance.
This includes felony, misdemeanor, serious traffic offenses, serious civil charges or military charges but does not include minor misdemeanors such as parking tickets or minor civil actions such as zoning violations or minor traffic violations such as moving violations when the individual was not physically taken into custody,
It also includes the mandated implementation of a plan for treatment or mitigation in order to avoid a permanent record of an arrest or convictions in response to the following:
(1) The use, sale or possession of illegal drugs (including controlled substances determined to be illegal under federal law, such as marijuana, but deemed legal under a state law);
(2) The abuse of legal drugs or alcohol; or
(3) The refusal to take a drug or alcohol test.
This does not include minor misdemeanors such as parking tickets, minor civil actions, such as zoning violations, or minor traffic violations such as moving violations when the individual was not physically taken into custody, provided the legal action did not include use, sale, or possession of illegal drugs; abuse of legal drugs or alcohol; or refusal to take a drug or alcohol test.
By my signature below, I certify that I have read this notification and understand my obligation to report legal actions from the signing of this document until authorization is terminated.
Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, D.C. 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA.
For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau 1700 G Street N.W., Washington, D.C. 20552.
You may have additional rights under Maine’s FCRA, ME. Rev. Stat. Ann. 10, Sec1311 et seq.
You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
a person has taken adverse action against you because of information in your credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:
You have the right to ask for a credit score.
Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information.
If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information.
Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information.
In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited.
A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
You must give your consent for reports to be provided to employers.
A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
You may limit "prescreened" offers of credit and insurance you get based on information in your credit report.
Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888--567-8688).
You may seek damages from violators.
If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights.
For more information, visit www.consumerfinance.gov/learnmore.
|TYPE OF BUSINESS:
1.a, Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.
b, Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:
a, Bureau of Consumer Financial Protection Bureau
1700 G Street NW
Washington, DC 20552
b, Federal Trade Commission: Consumer Response Center —
Washington, DC 20580
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d, National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
|3. Air carriers
Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue SE
Washington, DC 20590
|4. Creditors Subject to Surface Transportation Board
Office of Proceedings, Surface Transportation Board
Department of Transportation
395 E Street SE
Washington, DC 20423
|5. Creditors Subject to Packers and Stockyards Act
||Nearest Packers And Stockyards Administration area supervisor
|6. Small Business Investment Companies.
Associate Deputy Administrator for Capital Access
United States Small Business Administration
409 Third Street, SW, 8th Floor
Washington, DC 20416
|7. Brokers and Dealers
Securities and Exchange Commission
100 F St NE
Washington, DC 20549
|8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
|9. Retailers, Finance Companies, and All Other Creditors Not Listed Above
FTC Regional Office for region in which the creditor operates or
Federal Trade Commission: Consumer Response Center — FCRA Washington, DC 20580