Attachment_J-4_FDA_Form_3391.pdf

ATTACHMENT J-4

FDA Form 3391, “Security Card Access Request

CONTRACT EXPIRATION

SSN

FORM FDA 3391 (2/06)

CRED NUMBER

NEW

BUILDING

COMPANY NAME

DATE OF BIRTH

Male

Staff Fellow

FRONT

COMPLETE ONLY IF YOU ARE AN FDA CONTRACT EMPLOYEE

(See Privacy Act Statement on Reverse)

Female

OFFICE PHONE NUMBER

COLOR OF HAIR

U.S. CITIZENSEX

CENTER

Other (Explain) :

COLOR OF EYES

Inches

PHONE NUMBER (PROJECT OFFICER)

Intern

PLEASE TYPE OR PRINT INFORMATION

Visiting Scientist

FDA PROJECT OFFICER’S SIGNATURE

CONTRACT NUMBER

DATE

FDA SECURITY CARD

ACCESS REQUEST

FOR SECURITY OFFICE USE ONLY

EMPLOYEE ID NO.

CLASS

CHECK ONE:

Feet

Type of ID

SA CLASS

Lbs.

WEIGHT

No

Guest Worker

Yes

SECURITY REPRESENTATIVE’S SIGNATURE (Sponsor)

FellowshipStudent

ROOM NUMBER

Volunteer

Number on ID Type of ID Number on ID

YearMonth Day YearMonth Day

REGISTRAR SIGNATURE (Personnel Security) ISSUER SIGNATURE (Badging Office)

Special Government Employee

TERM OF APPOINTMENT

YearMonth Day YearMonth Day

EF

FULL NAME (Last, First, MI) OTHER NAMES USED (Maiden, Nickname, etc.)

REVISED

Department of Health and Human Services Food and Drug Administration

REISSUE

HEIGHT

VEHICLE TAG NUMBER

MAILING SYMBOL

STATE

LABORATORY PHONE NUMBER

PREVIOUS EDITIONS ARE OBSOLETE

YearMonth Day YearMonth Day

YearMonth Day YearMonth Day

ID NUMBER 1 ID NUMBER 2

PSC Graphics: (301) 443-1090

PRIVACY ACT STATEMENT

Authority

This information is provided pursuant to Public Law 93-597 (Privacy Act of 1974), December 31, 1974, for individuals applying for FDA Security Card Keys. Federal Property Management Regulations, 41 CFR 101.20.301, authorize the maintenance of systems by Government agencies for identifying individuals as employees in order to restrict access to Federal buildings after normal working hours and to areas not open to the general public.

Purposes and Uses

The principle purpose of the FDA Security Card Access Request, Form FDA 3391, is to maintain a record of all holders of the FDA Security Card Keys, for renewal and recovery purposes. This form is available only to personnel in the office issuing the Card Keys and the only information taken from it that may be given in response to inquiries is the office phone number, mailing symbol, and/or room number of the employee. Information may be disclosed to a congressional office at the request of the subject individual or to the Department of Justice in the case of litigation.

Effects of Nondisclosure

Failure to complete Form FDA 3391 will result in refusal to issue a Card Key.

Privacy Act Record Number 09-10-0018

FORM FDA 3391 (2/06) BACK