August 5, 1981
Memorandum for: Dr. C. Everett Koop
From: Fred F. Fielding
Subject: Personal Data Statement
As part of the clearance procedures relating to your proposed appointment, it is requested that you answer the following questions and supply the following information to us on a confidential basis.  Please note that federal law and regulations governing conflicts of interest require the disclosure of the information requested in question l-5, inclusive, as it pertains to you, your spouse and any relatives living in your immediate household.  In addition, you are requested to supply any information you deem to be relevant with regard to your spouse or such relatives when responding to any of the other questions.
In order that we might complete all necessary reviews as soon as possible, it is requested that you supply this information at your very earliest convenience.
If you have any questions or if this office can be of assistance, please do not hesitate to contact me.
1. The names of all corporations, firms, or other business enterprises, partnerships, nonprofit organizations, and educational or other institutions with which you are now or have ever been in the past connected as an officer, owner, director, trustee, partner, advisor, or consultant.  Those organizational affiliations which you might wish to continue during the term of your appointment should be noted with an asterisk.  (Please note that in the case of an attorney's client listing, it is only necessary to provide the names of major clients and those which might present a potential conflict or appearance of conflict with your proposed appointment).
2. The names of all corporations, partnerships or other institutions in which you have any financial interests through the ownership of stock, stock options, bonds, or other arrangements, including trusts.  Any interests you wish to retain during your period of government service should be noted with an asterisk.
3. The names of any creditors (other than those to whom you may be indebted by reason of a mortgage on property used as a personal residence or to whom you may be indebted for current and ordinary living expenses), setting forth the amount of such debt, any additional information deemed relevant to explain the transaction.
4. All your interests in real property, other than a personal residence, setting forth the nature of your interest, the type of property, and the address.
5. The name of all corporations, firms, or other business enterprises, partnerships, nonprofit organizations, and educational or other institutions, with which you have any continuing financial interests through present employment or by reason of a pension or retirement plan, stock bonus, profit-sharing, or other arrangement as a result of any current or prior employment or business or professional association. Also, supply such details as are necessary for a thorough understanding of such continuing financial interests.
6. Any employee fringe benefits you are now receiving and would desire to retain during your government service.
7. The details of any contractual or informal arrangement you may have with any business enterprise in regard to future employment.
8. Have you ever been convicted of a violation of any federal, state, county or municipal law, regulation or ordinance?  If so, please give full details (do not include traffic violations for which a fine of $25.00 or less was imposed).
9. Are you currently under federal, state or local investigation for possible violation of a criminal statute?  If so, please give full details.
10. Has a tax lien or other collection procedure ever been instituted against you by federal, state or local authorities?  If so, please give full details.
11. Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct by, or been the subject of a complaint to, any court,
administrative agency, professional association, disciplinary committee, or other professional group? If so, please give full details.
12. Have you ever been involved in civil litigation, or administrative or legislative proceedings of any kind, either as plaintiff, defendant, respondent, witness, or party in interest?  If so, please give full details.
13. Have you ever run for political office, served on a political committee, or been identified in a public way with a particular political organization, candidate or issue?  If so, please, describe.
14. Have you ever been publicly identified, in person or by organizational membership, with a particularly controversial* national or local issue?  If so, please describe.
15. Have you ever submitted oral or written views to any government authority (executive or legislative) or the news media, on any particularly  controversial* issue other than in an official governmental capacity? If so, please describe.
16. Have you ever written any particularly controversial* books or articles?  If so, please list them, giving the citations, titles and dates.
17. Have you ever had any association with any person or group or business venture which could be used, even unfairly, to impune or attack your character and qualification for this position?
18. Do you know anyone who might take any steps, overtly or covertly,  to attack your appointment? If so, please identify and provide the basis of the
potential attack.
19. Please provide any other information which you regard as pertinent or which could be the possible source of embarrassment to you, or to the President, if publicly known.
* Reference to "particularly controversial" is intended to focus on issues that could be used, even unfairly, against you.