Form 511, 2015, Bureau Of Reclamation Pre-Appointment Background Check List For Critical Sensitive Positions Page 4
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4SLE 01-01
Appendix B
Reclamation Manual
Directives and Standards
Form B4. Bureau of Reclamation Pre-Appointment Background Check Form for Non-
Critical/Critical Sensitive Law Enforcement Positions.
P re-appointment Background Check in support of an Investigative Requirement Waiver Request Check List
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Date:____________________________ Position Applied For:______________________________________
Name:_______________________________________________________ DOB:_______________________
SSN:_______________________________________POB:__________________________________________
Home Address:_____________________________________________________________________________
M ANDATORY PRE-APPOINTMENT CHECKS IN SUPPORT OF A WAIVER REQUEST
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R EQUESTING OFFICE RESPONSIBILITY
: (attach all results)
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* Driver’s License (Verification of Record):
Yes___ No___ No Record___
* Reference Checks (notes if completed):
Yes___ No___ N/A___
* Subject Interview (notes if applicable):
Yes___ No___ N/A___
* National Crime Information Center (NCIC):
Yes___ No___
H R OFFICE RESPONSIBILITY
: (attach a copy of each form)
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* Military Records (DD-214):
Yes___ No___ N/A___
* OF-306 Screening Completion Notice:
Yes___ No___ N/A___
* OF-612 or Resume:
Yes___ No___ N/A___
* Applicant’s Contact Info for e-QIP: E-Mail Address:_________________ Phone:___
________
S SLE RESPONSIBILITY
:
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* OPM/Security Investigation Index (SII):
Yes___ No___ No Record___
* Signed SF-86 general release & FCRA form:
Yes___ No___
* Local Law Enforcement Agencies:
Yes___ No___
* Credit History:
Yes___ No___ No Record___
* SF-86 Review of
* Employment History:
Yes___ No___
* Residence History:
Yes___ No___
* Education/Training:
Yes___ No___
* References:
Yes___ No___
* Other Checks/Information:
Yes___ No___ N/A___
Requesting Office’s Representative
Who Conducted Checks:
Checks Reviewed and Concurred By:
_________________________________________
__________________________________________
Print Name & Signature
SSLE Personnel Security Officer (or designee)
_________________________________________
__________________________________________
Date & Office Telephone Number
Date & Office Telephone Number
*ATTACHMENTS: List all pertinent reference material (including results of interviews, record checks, vouchers, etc.).
Also attach a copy of all available documents and an explanation for any unavailable document.
Modification B4 of DI-1990
(511) 02/02/2015
Page B4
SUPERSEDES SLE 01-01 (363) 09/29/2009 and minor revisions approved 09/29/2010
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