Bioterrorism Security Risk Assessment Form
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Instructions The Bioterrorism Security Risk Assessment Form helps the FBI conduct 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. If you are a first time applicant, the FD-961 form can be completed online using the link above, printed, and mailed with the fingerprint cards as a complete package to the Criminal Justice Information Services (CJIS) Division. For renewals, repeats, or reactivations, the form can be completed online, printed, and faxed to the CJIS Division at (304) 625-2198. The fingerprint card packages consist of two fingerprint cards, general instructions, fingerprint instructions, and a pre-addressed return envelope. These packages can be obtained via faxing a request to the FBI at (304) 625-3984. The faxed request should include the following: the entity name, point of contact or requesting office, the correct mailing address, contact telephone number, and how many fingerprint card packets are requested. In order for the security risk assessment to be processed in a timely manner, the FD-961 form and two legible fingerprint cards must be returned to the FBI as one package. The FBI will not conduct a security risk assessment for an individual unless it has received a completed FD-961 form and two legible fingerprint cards. For questions concerning who needs to complete the FD-961 form, please see the frequently asked questions posted on the Select Agent webpage. General Guidance on Completing the FD-961 Form Section I
Block 1: Provide the legal name of the entity and the entity application number supplied by U.S. Department of Agriculture's Animal and Plant Health Inspection Service (APHIS) or the Centers for Disease Control and Prevention (CDC). Block 3: Indicate the type of applicant by following the guidelines:
Section II Block 4: Include full name (last, first, middle, and suffix, e.g. Jr. or III). The name provided in block 4 should be identical to that indicated on Table 4 of CDC form APHIS/CDC form 1. Block 4a: Include any aliases/maiden names. Block 11: Ensure the unique identifying number supplied by APHIS or CDC for the individual is provided. CDC or APHIS will provide to the requesting office a unique identifying number for each individual listed on Table 4 of CDC form APHIS/CDC form 1. Information about how to obtain a DOJ number is available on the Internet at http://www.aphis.usda.gov/programs/ag_selectagent/ag_bioterr_QA.shtml or www.selectagents.gov. Block 12a-12h: Answer all questions located in blocks 12 a-h with a "yes" or "no" in the boxes provided. Questions concerning completion of the FD-961 form can be directed to the Bioterrorism Help Line at (304) 625-4900. Completion of Fingerprint Cards First time applicants will be provided with two fingerprint cards to have printed by a local law enforcement agency. Individuals or entities must arrange for this service. In most instances, the law enforcement offices will charge a fee for this service. The two fingerprint cards and the completed FD-961 form must be submitted to the FBI in the provided envelope in order to process the security risk assessment. 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. Once printed, the two fingerprint cards and the completed FD-961 form must be forwarded to the FBI. In order for the security risk assessment to be processed in a timely manner, the FD-961 form and fingerprint cards must be returned to the FBI as one package mailed in the pre-addressed envelope. If not using the pre-addressed envelopes, please submit completed packages to: Bioterrorism Security Risk Assessment Group E-3 The FBI will not conduct a security risk assessment for an individual unless it has received a completed FD-961 form and two legible fingerprint cards.
Additional Requirements
Under any case where an individual is changing employers, reactivating employment or completing a security risk assessment renewal, the individual must submit a completed FD-961 form to the FBI via mail or fax. Two fingerprint cards are not required if a legible set is already on file with the FBI. The FBI reserves the right to request additional fingerprint cards in the future if necessary. A full security risk assessment must be completed prior to an individual being granted access to select agents and toxins at the new place of employment. The security risk assessment granted under previous employment is NOT transferrable. 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 and Routine Uses The information collected on this form will be used for the principal purpose of conducting security risk assessments for entities that possess, receive, use and/or transfer select agents and toxins; individuals who own or control an entity; individuals authorized to have access to select agents or toxins; and responsible officers. As part of this assessment, the collected data 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. Additionally, information provided in all or part of this completed form may be disclosed to Department of Justice personnel who need the information in the performance of their duties and outside the Department of Justice to HHS and/or USDA for the purpose of making security risk assessments and other determinations relating to individuals, entities, and responsible officers that have access to or possess, use, receive and/or transfer select agents and toxins; to federal, state, local, joint, tribal, or international entities charged with the responsibility of investigating, prosecuting, and/or enforcing laws, regulations, rules, orders or contracts if any part of the information received, either on its face or in conjunction with other information, indicates a violation or potential violation of law, regulation, rule, order, or contract; to any law enforcement or intelligence authority or other federal, state, or local entity with relevant jurisdiction where such information reveals a risk to human, animal, and/or plant health or national security; to organizations or individuals, both public and private, if deemed necessary, in the sole discretion of the U.S. Department of Justice, to elicit information or cooperation from the recipient for use in assessing suitability to access, possess, use, receive, or transfer select agents and toxins; and pursuant to the routine uses most recently published in the Federal Register for the FBI's Central Records System (Justice/FBI-002) and the FBI's Blanket Routine Uses (Justice/FBI-BRU). Social Security Account Number Your Social Security number (SSN) 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 SSN 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. Effects of Nondisclosure Completion of this form and provision of your SSN is voluntary. However, failure to provide the requested information may result in a finding that you may not have access to a select agent or toxin because of an incomplete application or an unapproved 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. The estimated average burden associated with this collection of information is 45 minutes, depending on circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to Bioterrorism Security Risk Assessment Mod E-3, Criminal Justice Information Services Division, 1000 Custer Hollow Road, Clarksburg, WV 26306. |
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