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The document outlines the purpose and authority of a privacy collection program for pre-employment medical evaluation, including SSN collection, routine uses, and consequences for non-disclosure. 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INSTRUCTIONS FOR COMPLETING FORM  \u003Cbr>(PLEASE DO NOT WRITE IN“EXAMINING FACILITY USE ONLY”AREAS)  \u003Cbr>SELECTEES Complete page 1 through 8 before reporting for the medical examination.Please print or type.Each“yes”  \u003Cbr>answer to a medical history question requires that you provide a brief explanation in the comment section provided.  \u003Cbr>Failure to answer any questions or disclose a known medical condition or history of a medical condition or  \u003Cbr>injury or failure to place signature where indicated may result in removal from further consideration for  \u003Cbr>employment.This examination is being conducted for employment purposes only;it does not substitute for a periodic  \u003Cbr>health examination conducted by your private provider.  \u003Cbr>(NOTE:This exam may include a fitness test,please dress appropriately.)  \u003Cbr>*ATTENTION VETERANS:All mental health counseling or treatment,to include counseling that was “strictly related to  \u003Cbr>adjustments from service in a military combat environment\",must be disclosed on this Medical Examination and History  \u003Cbr>Report form to determine if you meet the medical qualifications for the position.   |  |  |\n| PRIVACY ACT STATEMENT  \u003Cbr>AUTHORITY:5 C.F.R.§339,Medical Qualification Determinations authorize the collection of this information.  \u003Cbr>Collection of your Social Security Number(SSN)is authorized by Executive Order 9397,as amended.  \u003Cbr>PURPOSE:Your information is being collected to perform a pre-employment medical examination.This form is used as  \u003Cbr>part of the pre-employment hiring process which collects information for the purpose of employment consideration.  \u003Cbr>ROUTINE USES:Your SSN will be used to uniquely identify you.For United States Citizens,Lawful Permanent  \u003Cbr>Residents,or individuals whose records are covered by Judicial Redress Act of 2015,5 U.S.C.§552 a note,your  \u003Cbr>information may be disclosed in accordance with the Privacy Act of 1974,5 U.S.C.§552a(b),including pursuant to thee  \u003Cbr>routine uses published in the OPM/GOVT-1,General Personnel Records System of Records Notice (SORN),OPM  \u003Cbr>GOVT-5-Recruiting,Examining,and Placement Records SORN,and OPM/GOVT-10-Employee Medical File SORN  \u003Cbr>and which can be viewed at www.dhs.gov/privacy.  \u003Cbr>DISCLOSURE:Funishing this information,including your SSN is voluntary;however,if you do not provide the  \u003Cbr>information then ICE may determine you are ineligible for employment.   |  |  |\n| SELECTEE’S NAME (Last,First,Middle Initial):   |  | SOCIAL SECURITY NUMBER(SSN)/  \u003Cbr>IDENTIFICATION (ID)NUMBER:   |\n| VETERAN'S PREFERENCE ELIGIBILITY:  \u003Cbr>□ Yes □No  \u003Cbr>If yes,specify below:  \u003Cbr>□10-point reference  \u003Cbr>□5-point preference   | SEX:  \u003Cbr>□Male □ Female   | DATE OF BIRTH (mm/dd/yyyy):   |\n| YOUR CURRENT OCCUPATION:   | YOUR CURRENT EMPLOYER:   |  |\n| HOWLONG IN CURRENT POSITION?(years/months)   |  |  |\n| PURPOSE OF EXAMINATION:  \u003Cbr>□Pre-Employment Exam    □ Periodic Exam   |  |  |\n| CHECK THE OCCUPATION FOR WHICH YOU ARE BEING CONSIDERED:  \u003Cbr>□ Criminal Investigator (GS-1811)  \u003Cbr>□ Deportation Officer (GS-1801)  \u003Cbr>□Police Officer(GS-0083)  \u003Cbr>□ Law Enforcement Training Specialist (GS-1701)  \u003Cbr>□Physical Security Specialist (GS-0800)  \u003Cbr>□ Other:__   |  |  |\n\n\n| Health care professionals and examiners:Please avoid adding Pll in comments.   |  |  |  |\n| --- | --- | --- | --- |\n| SELECTEE’S NAME:   |  | SSN/ID NUMBER:   | DATE:   |\n| EXAMINING FACILITY USE ONLY   |  |  |  |\n| EXAMINING FACILITIES:(Do NOT bill examinee for exam.The vendor is responsible for all payments.)Conduct  \u003Cbr>medical exam and all other required services in accordance with instructions provided by the contracting organization.  \u003Cbr>Complete this form except where indicated.Please print or type.   |  |  |  |\n| NAME AND ADDRESS OF EXAMINING FACILITY:   | NAME OF EXAMINER:   |  |  |\n|  | PHONE NUMBER","cbCaieptxKI6FYOg","https://ap.wps.com/l/cbCaieptxKI6FYOg","pdf",1397664,16,"English","# Instructions for Completing Form\n## Selectees and Medical History Requirements\n## Privacy Act Statement\n# Examination and Required Services\n## Required Services Checklist\n## Selectee Medical History Questions","[{\"question\":\"What should selectees do before reporting for the medical examination?\",\"answer\":\"Complete pages 1 through 8 before reporting and print or type the information as instructed. Each “yes” answer to a medical history question requires a brief explanation in the provided comment section.\"},{\"question\":\"What is the purpose of collecting information on this form?\",\"answer\":\"The information is collected to perform a pre-employment medical examination as part of the pre-employment hiring process to determine employment consideration.\"},{\"question\":\"What happens if a selectee does not provide the requested information, including SSN?\",\"answer\":\"Disclosure of the information is voluntary, but if it is not provided then ICE may determine the selectee is ineligible for employment.\"}]","MEDICAL EXAMINATION AND HISTORY REPORT - Instructions and Privacy Act Statement | PDF",1789748723]