AUTHORIZATION AND CONSENT TO RELEASE PERSONAL RECORDS IN
          CONNECTION WITH THE PERSONNEL ASSURANCE PROGRAM (EXAMPLE)


    I, _______________________ (applicant's/employee's full name), am
seeking certification or recertification in the Personnel Assurance Program
(PAP).

    I understand that the PAP certification or recertification process will
generate medical and nonmedical records relevant to my eligibility for the
PAP.  I recognize that these records are protected by the Privacy Act of
1974, as amended.

    For purposes of this consent, my PAP records include, but are not
limited to, any records generated by a preemployment check performed by
either ______________________________________________ (DOE contractor's
corporate/organization name, hereinafter "Corporation") or the Department of
Energy (DOE):  medical records, including but not limited to, medical
histories, results of medical examinations and tests to determine alcohol
abuse, and the results of psychological examinations and/or tests; and the
results of urine tests taken to determine the presence of illegal drugs or
alcohol in my body.

    I hereby consent that the foregoing PAP records, and any of them, may be
disclosed to the appropriate Organization management and DOE officials who
have a legitimate need for the records in the performance of their duties
and responsibilities in the PAP certification, recertification, or
decertification process.

    I acknowledge that such disclosure in connection with the PAP is an
approved disclosure in accordance with 5 USC 552a(b)(1).  I further agree
that this document will serve as written consent to the disclosure of the
PAP records to the appropriate Organization management and DOE officials
within the meaning of the Privacy Act.

    I further waive any rights and release the Organization, DOE, and any
and all individuals, including DOE contractor medical department personnel,
from liability under the Privacy Act 5 USC 552a, the U.S. or state
constitutions, any other applicable federal or state statutes, any
applicable physician-patient privilege, and common law claims of any nature
whatsoever, for disclosure of my PAP records to Organization management or
DOE officials with a legitimate need for the records in the performance of
their responsibilities in the PAP certification, recertification, or
decertification process.

    My signature below acknowledges that I have read and understand the
foregoing authorization and consent agreement.


__________________________    _____________________________
Date                          Employee

     _______________________________
               Supervisor