Attachment_4-NOAA_Security_Form_OSY_Action_Request.pdf

U.S. Department of Commerce - Office of Security Security Coversheet / Request for Investigation Coversheet

Date:________________________

Legal Name (First, Middle, Last) Other Names Used (example: Maiden Name)

Social Security Number

Gender Date of Birth (MM/DD/YYYY) Male Female

Place of Birth (City, State, Country) Country of Citizenship Dual Citizenship Subject’s Email Address

Visa Number Alien Registration Number

Position Title Geographic Code (If Employee) Nature of Action Code (If Employee) Duty Station (complete address)

Start Date (EOD) End Date Contract Company Contract Number Supervisor / COR Supervisor’s / COR’s Phone # HR/COR/Sponsor Email HR/COR/Sponsor Signature Previous Federal / DOC Work Dates

Type of investigation (check one)

Prints (less than 30 days)

SAC

(less than 179 days)

Tier 1 Tier 2S

Tier 3 Tier 4 Tier 5 Reinvestigation

Position Sensitivity (check one)

Low Risk Moderate Risk High Risk Noncritical-Sensitive Critical-Sensitive Special-Sensitive

Mandatory Financial Fields for Processing Background Investigations Treasury Account Symbol (TAS) *fill in all active fields

SP ATA AID BPOA EPOA A Main Sub Format C

Accounting Data Organization code Project code

NOTES:

1. It is critically important that the TAS fields are accurately populated because they identify the fund account that will be used to pay for your investigation. If you don’t know your TAS code you will need to consult your local finance or budget office.

2. Treasury Account Symbol must be provided and all fields completed. No actions will be processed without this information.

3. You must complete additional requirements listed in DAO 207-12 to obtain authorization for foreign national access to a DOC facility. Please contact your Servicing Security Office if you have any questions.

4. Do not email this when filled-out. It will contain Personally Identifiable Information (PII).

Revised 01/01/2017

Status: Volunteer/Student Federal Employee Associate/Guest Contractor Foreign National *(See Note 3)

Bureau / Line Office

TIER 1 (PREVIOUSLY NACI) TIER 3 (PREVIOUSLY ANACI) TIER 5 (PREVIOUSLY SSBI)

TIER 2S (PREVIOUSLY MBI) TIER 4 (PREVIOUSLY BI)

5.