OSR form 10-302.pdf

Created by: Jasmine Coleman OSR 10-302 # (Rev 3-1-2005)

Status: Draft

Subcontractor Reque.t for New Security Badge or Site Acce•• Authorization.

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Section 1 Dates and Validation

GET (date) Badge Office Only

D Scheduled

CAT (date) Exgiration Date

SubContract End Date

FOCINOF End Date(Personnel Securitv onlv) Substance Abuse Notified:

Section 2 - General I Todays Date Subcontract No Subcontractor Name Badge Auth I Company I

IAGRISU use the select button I I Lower Tier Subcontract No. Lower Tier SubContract End Date Lower Tier Subcontractor Name

Beason For Badae Reauest D Change Subcontract No. D New EmployeeU Area Access Change

D Appearance Change D Name Change (Complete DOE F 5631.34) D New/Changed Clearance

D Damaged Badge D Lost Badge D Annual "Q" - (OSR -10-232)

DHRP D Change Company D Renewal

D Downgrade

Get Reason Stringl

Section 3 - Subcontract Emolovee Information Last Name First (Legal) IMiddle Iinitials INickname l':Sr., etc.

Social Security No. ~.Citizo Iuser 10 IDate of Birth IGender Yes No I o Female 0 Male

UManual Employee rork Location ork Phone No. rermanent Home Phone No.o not applicable Permanent Home Mailing Address (Street Address) I~ity and State FiP Code

Is this request for a Recovery Act employee ? o Yes 0 No

Section 4 - Aoorovals Subcontract Technical Representative ISTR User 10 (Required) I STR Work Location ISTR Phone No.

Note - Additional approvals are required for many areas on the site. See Section 5A through 5C for more information

Section 5 - Area Access Authorizations Reauested .

This section is used to request Area Access Authorizations. Do not request authorizations for facilities to which the employee is not routinely assigned. Questions concerning facilities to be accessed should be directed to the SRS Badge Office at725-3347, 725-3348, 725-5049, 725-3929. Approval signatures required.

Section 5A

Proximity Card Required? o Yes 0 No Emergency Access Required? o Yes 0 No

I TYRe Badge Reguested

("E" on the Photobadge) rE OL OQ o Uncleared

Section - 5B (PA) Approved Signatures Required Section - 5C (MAA) Approved Signatures Required Select Area / Approver I Select Area / Approver

100-K Operations/Facility Manager Approval Reactor Operations/Facility Manager Approval

100 L Operations/Facility Manager Approval 221-HB Line Facility Manager Approval

200-H Tritium Facility Manager Approval

Emergency Preparedness Coordinator Approval

Other (CAS) lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight lmoore02 Highlight