| This document is available in three formats: this web page (for browsing content), PDF (comparable to original document formatting), and WordPerfect. |
INSTRUCTIONS: This form is to be completed by all employees upon initial employment (accession) and whenever any information on the form changes. Changes should be promptly recorded by submission of this form to your administrative office. In accordance with the provisions of the Privacy Act of 1974, submission of some data is MANDATORY. Other data is requested on a VOLUNTARY basis for the safety and convenience of the employee. The MANDATORY or VOLUNTARY nature of the data is indicated in the applicable Privacy Act Statement. Certain portions of the form are to be completed by the employee's personnel office or administrative office. Employees should leave these portions of the form blank. If you have any questions regarding completion of the form, please consult your Administrative Office. EMPLOYEE INFORMATION PRIVACY ACT STATEMENT: SOCIAL SECURITY NUMBER-1. AUTHORITY: Executive Order 9397 dated November 22, 1943. 2. PURPOSE AND USE: The Social Security Number (SSN) is used as a unique identifier for matching locator records in personnel and payroll files. Use of the SSN ensure correct identification of records with the same name. EFFECTS OF NON-DISCLOSURE: Disclosure of the SSN is MANDATORY. Failure to disclose the SSN while reporting changes will result in the changes not being effected. Social Security Number:_____________-___________-________________ Date:_______________________ NAME (LAST, FIRST, MI):_____________________________________________________________________ PRIVACY ACT STATEMENT: TELEPHONE NUMBER-1. AUTHORITY: 5 U.S.C. Sections 301 2. PURPOSE AND USE: To contact employees at their residence on matters of an official nature relating to their employment with the Department of Justice. Access to this information is limited to the employee's supervisor(s) OR individuals authorized by the supervisor(s). 3. EFFECTS OF NON-DISCLOSURE submission of this data is VOLUNTARY. If the data is not submitted, supervisory personnel may have difficulty locating employees to inform them of emergency work situations. HOME PHONE: (___________)______________-______________________________ EMERGENCY CONTACT INFORMATION PRIVACY ACT STATEMENT: EMERGENCY LOCATOR-1. AUTHORITY: 5 U.S.C. Sections 301, 7901. 2. PURPOSE AND USE: To obtain emergency treatment or to notify friends or family in the event of employee injury or illness. 3. EFFECTS OF NON-DISCLOSURE: Submission of this data is VOLUNTARY and solely for the employee's safety and convenience. EMERGENCY CONTACT (LAST, FIRST):_________________________________________________________________ Relationship:__________________________________________________________________________________________ PHONE NUMBER: (_________)__________-_________________, EXT _____________________ OFFICE ADDRESS NAME OF EMPLOYING ORGANIZATION U.S. DOJ, Antitrust Division POI 1830 AGENCY CODE HC ORGANIZATION STRUCTURE (2-4) _________________________________________________ BUILDING CODE __________ ROOM NUMBER ________ BUILDING NAME _____________________________________ BUILDING ADDRESS _________________________________________________________________________________ OFFICE PHONE (_________)__________-_________________, EXT _____________________ FORM DOJ-543 |