Public Servant Questionnaire

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Public Law 93-579 states in part:
                  “The purpose of this Act is to provide certain safeguards for an individual against invasion of privacy by requiring federal agencies… to permit an individual to determine what records pertaining to him are collected, maintained, used, or disseminated by such agencies.”


The following questions are based upon that act and are necessary in order that this individual may make a reasonable determination concerning divulgence of information to this agency.

 

1.     Name of public servant:        _____________________________________________________________

2.     Residence address        __________________________________________________________________

____________________________________________________________________________________________

3.     Name of department of government, bureau, or agency by which public servant is employed:

____________________________________________________________________________________________

        Supervisor’s name        __________________________________________________________________

4.     Agency mailing address        _____________________________________________________________

____________________________________________________________________________________________

5.     Will public servant uphold the Constitution for the United States?         ________________________

6.     Did public servant furnish proof of identity?   _______________________________________________

7.     What was the nature of the proof?        ____________________________________________________

8.     Will public servant furnish a copy of the law or regulation authorizing this investigation?   _____________

9.     Will the public servant read aloud that portion of the law authorizing the questions s/he will ask?   _______

10.   Is answering these questions voluntary or mandatory?             _______________________________

11.   Are your questions based upon a specific law or regulation, or are they being used as a discovery process?    ____________________________________________________________________________________________

12.   What other uses may be made of this information?   _________________________________________

13.   What other agencies may have access to this information?    __________________________________

14.   What will be the effect upon me if I should choose to not answer any part or all of these questions?

____________________________________________________________________________________________

15.   Name of person in government requesting that this investigation be made:   ____________________

16.   Is this investigation “general” or is it “special”?     ____________________________________________

17.   Have you consulted, questioned, interviewed, or received information from any third party relative to this

        investigation?    _________________________________________________________________________

18.   If so, what is the identity of such third parties?    ____________________________________________

19.   Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any

        of the information which you seek?    ______________________________________________________

20.   Is there a file of records, information, or correspondence relating to me being maintained by this

        agency?   ______________________________________________________________________________

21.   Is this agency using any information pertaining to me that was supplied by another agency or

        government source?    ___________________________________________________________________

22.   Have you inspected any information or document relating to me from this agency or any other? ________

23.   May I inspect these files?   ________________________________________________________________

24.   Mai I have a copy of these files?  __________________________________________________________

25.   Will the public servant guarantee that the information in these files will not be used by any department

        other than the one by whom s/he is employed?   ___________________________________________

        If not, why not?    ______________________________________________________________________

 

I SWEAR (OR AFFIRM) THAT THE ANSWERS I HAVE GIVEN TO THE ABOVE QUESTIONS ARE COMPLETE AND CORRECT IN EVERY PARTICULAR.

 

                                                                                  _________________________________________

                                                                                  Signature of Public Servant

____________________________________________________________________________________________

Authorization for Public Servant Questionnaire


If any request for information relating to me is received from any person or agency, you must advise me in writing before releasing such information.  Failure to do so may subject you to civil or criminal action as provided by the Act.

The Privacy Act of 1974 (Public Law 93-579) is an amending law to Title 5, United States Code, section 552; and is included in Title 5 as section 552a.  This Act gives me full rights to know what information is being collected and maintained about me and for what uses and purposes (see Sec. 2(b)(1)).

 

 

QUESTION NUMBER               AUTHORIZATION

1, 2, 3, 4                                  In order to be sure exactly to whom I am furnishing information, residence and addresses are needed in case I need to serve process on this individual in a civil or criminal action.

5                                             ALL public servants have taken a sworn oath to uphold and defend the Constitution. A copy of this oath may be obtained under the Freedom of Information Act, and by writing the Government Employment or Civil Service Office.

6, 7                                         This is standard procedure by government agents and officers.  I.R. Manual MT-9900-26, section 242.133.

8, 9, 10                                    Title 5, U.S. Code, section 552a, paragraph (e)(3)(A)

11                                            Title 5, U.S. Code, sect. 552a, paragraph (d)(5)(e)(1)

12, 13                                      Title 5, U.S. Code, sect. 552a, par. (e)(3)(B & C)

14                                            Title 5, U.S. Code, section 552a, paragraph (e)(3)(D)

15                                            Public Law 93-579 (b) (1)

16                                            Title 5, U.S. Code, section 552a, paragraph (e)(3)(A)

17, 18                                      Title 5, U.S. Code, section 552a, paragraph (e)(2)

19                                            Title 5, U.S. Code, section 552a, paragraph (d)(5)

20, 21, 22                                 Public Law 93-579 (b) (1)

23, 24                                      Title 5, U.S. Code, section 552a, paragraph (d)(1)

25                                            Title 5, U.S. Code, section 552a, paragraph (e)(10)

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