Attachment_11_Department_of_Health_and_Human_Services_(HHS)_identification_(ID)_Badge_Request_(HHS-775).pdf

HHS-745 (5/07) Page i

Applicant Instructions for Completing Form HHS-745, "HHS ID Badge Request"

Section A collects identifying information about Applicants needed to issue an HHS ID Badge. In some Federal agencies, Sponsors or other authorized officials will complete this section for Applicants. If you are an Applicant and are asked to complete Section A, follow the instructions below. During the ID Badge issuing process, you also will be asked to complete Section F.

Clearly print all information except for your signature.

Section A

1. Check the appropriate box to indicate why a new HHS ID Badge is being issued. If you check "Other," please indicate the reason in the space provided.

2. Enter your full legal name on the first line. If you have used other name(s), enter these names on the "Other Name(s) Used" line.

3. Enter your date of birth in mm/dd/yyyy format.

4. Enter your place of birth (city and state if born in the U.S. or city and country if foreign born).

5. Enter your Social Security Number (xxx-xx-xxxx).

6. Check whether you are a U.S. citizen. If you are not a U.S. citizen, enter the country where you are a citizen.

7. Enter your position title (include series and grade level).

8. Enter where you will be working. This could include the center, office, group, division, or institute. If you are a contractor Applicant, enter the organizational chain for the COTR's or Project Officer's division.

9. Enter the physical location (building and office) of your office, work area, or contract office.

10. Enter your work telephone number. If none, then list Contract Officer's, COTR's, or Project Officer's telephone number.

11. Enter your email address.

Contractors and others employed outside the Federal government, complete items 12 through 14.

12. Enter your company's name.

13. Enter your company's address.

14. Enter your company's telephone number.

All Applicants complete items 15 and 16.

15. Sign to authorize HHS to conduct the identity proofing/verification process and to certify that you understand that actions may be taken against you if you provide false information on this form.

16. Enter the date you signed.

Sections B, C, D, and E will be completed by HHS.

Section F You will be given a copy of the Privacy Act Statement for this HHS ID Badge Request form and HHS ID Badge Rules.

72. Sign your name to certify that you have read and understand the Privacy Act Statement and HHS ID Badge Rules and that you agree to follow the HHS ID Badge rules.

73. Enter the date of your signature.

This page deliberately left blank.

HHS-745 (5/07) Page 1PSC Graphics (301) 443-1090 EF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Department of Health and Human Services (HHS) identification (ID) Badge Request

(Other Federal Departments may call this type of ID badge a Personal Identity Verifi cation [PIV] card)

HHS ID BADGE ISSUING FACILITY

IDENTIFICATION NUMBER

Privacy Act Statement: The information on this form is collected by the Department of Health and Human Services (HHS) to issue you an identification badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of government buildings, the people who work in them, and government computer systems. When you use your ID Badge an ID Badge system will verify that you are authorized to use government facilities. The system also will track and control the ID Badges that are issued. The authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal Facilities, June 28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social Security number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying your identity to process this application. The information on this form may be disclosed only with your written consent, except where permitted by the Privacy Act. The disclosures permitted by the Privacy Act include disclosure to: the Department of Justice, a court, or other government officials when the records are relevant and necessary to a law suit; the appropriate public authority (Federal, foreign, State, local, tribal, or otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation;

a Member of Congress or congressional staff member at your written request; the National Archives and Records Administration for records management inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to do agency work and who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide whether to retain an employee, continue a security clearance, or agree to a contract, grant, license or benefi t; Federal, State, or local agencies, entities, individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Office of Management and Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is no longer valid. If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will not have access to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the information may prevent you from being able to work.

A. Applicant Information (To be completed by Applicant, Sponsor, or Authorized Official)

1. REASON FOR ISSUANCE New Application Renewal Lost Stolen Damaged Expired

Other (specify):

2. NAME (Last, First, Middle) OTHER NAME(S) USED

3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH

5. SOCIAL SECURITY NUMBER (xxx-xx-xxxx)

City State or Province Country

6. U.S. CITIZEN

Yes No (specify citizenship):

7. POSITION TITLE 8. AGENCY / DIVISION

9. BUILDING / OFFICE ADDRESS 10. WORK PHONE

11. EMAIL

For Contractors, complete lines 12 through 14

12. ORGANIZATION / COMPANY NAME 13. ADDRESS OF ORGANIZATION / COMPANY

14. TELEPHONE OF ORGANIZATION / COMPANY

To be completed by Applicant

15. APPLICANT SIGNATURE 16. DATE (mm/dd/yyyy)

I hereby authorize the release of information in this application to appropriate Federal agencies for the purposes of processing this application and verifying my identity. I also acknowledge that if I knowingly provide or assist in the provision of false information or non-verifi able information, and/or I purposely omit information, it could result in loss of access to HHS facilities and IT systems and in disciplinary action including removal from Federal service or a Federal contract, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

HHS-745 (5/07) Page 2

B. HHS ID Badge Request (To be completed by Sponsor, after Section A has been completed)

17. ID BADGE TYPE (choose ALL that apply)

Foreign National HHS Employee Other Federal Employee:

Contractor Organizational Affiliate:

APPLICANT NAME

18. EMERGENCY RESPONDER

Yes No

For Contractors, complete lines 21 through 27 PROJECT OFFICER INFORMATION (if not Sponsor)

21. NAME (Last, First, Middle)

22. CENTER/OFFICE/GROUP/DIVISION

23. POSITION TITLE

24. WORK PHONE 25. EMAIL

I certify that the above Applicant will be participating on the contract identified on this form.

26. PROJECT OFFICER SIGNATURE

27. DATE (mm/dd/yyyy)

SPONSOR INFORMATION

28. NAME (Last, First, Middle)

29. SPONSOR ID NUMBER (or complete lines 30-33)

30. AGENCY/DIVISION

31. POSITION TITLE

32. WORK PHONE 33. EMAIL

For Contractors, complete lines 34 - 36

34. APPLICANT CONTRACT NO.

35. CONTRACT START (mm/dd/yyyy) 36. CONTRACT EXPIRATION (mm/dd/yyyy)

37. SPONSOR SIGNATURE 38. DATE (mm/dd/yyyy)

I agree to sponsor the above Applicant for an HHS ID Badge and certify that the information provided in Sections A and B are complete and accurate to the best of my knowledge. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifi able information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service and I may be subject to prosecution under applicable Federal criminal and civil statutes.

C. Identity Proofing (To be completed by Sponsor, Enrollment Official, or Registrar after Section B has been completed)

If the Applicant does not require a background investigation and is in possession of an undamaged, uncompromised, unexpired HHS ID Badge, you may complete all of Section C or only complete items 41-42 and 49-50.

39. COPIES OF ID SOURCE

DOCUMENTS ATTACHED? Yes No

40. DID APPLICANT PRESENT TWO FORMS OF IDENTIFICATION,

ONE OF WHICH WAS A PHOTO ID ISSUED BY A STATE OR THE

FEDERAL GOVERNMENT? Yes No

IDENTITY PROOFER INFORMATION

41. NAME (LAST, FIRST, MIDDLE)

42. IDENTITY PROOFER ID NUMBER

IDENTITY SOURCE DOCUMENT TWO

46. NAME

47. DOC. TITLE

48. DOC. EXPIRATION DATE (mm/dd/yyyy)

IDENTITY SOURCE DOCUMENT ONE

43. NAME

44. DOC. TITLE

45. DOC. EXPIRATION DATE (mm/dd/yyyy)

49. ID PROOFER SIGNATURE 50. DATE (mm/dd/yyyy)

I certify that the above Applicant appeared before me and presented two ID source documents, which to the best of my knowledge appeared to be genuine, or presented an undamaged uncompromised, unexpired HHS ID Badge and does not require a background investigation. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non- verifiable information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

Non-Sensitive (1) National Security/Secret or Confidential (2) National Security/Top Secret (3)

National Security/Top Secret - SCI (4) Public Trust/Moderate Risk (5) Public Trust/High Risk (6)

19. POSITION SENSITIVITY LEVEL

20. ID BADGE EXPIRATION DATE

(mm/dd/yyyy)

HHS-745 (5/07) Page 3

D. HHS ID Badge Approval (To be completed by Registrar, after Section C has been completed)

If the Applicant does not require a background investigation and is in possession of an undamaged, uncompromised, unexpired HHS ID Badge, you may complete all of Section D or only complete items 51 and 57-60.

APPLICANT NAME

51. RECIPROCITY VERIFIED (if applicable)

PIPS RECORD ATTACHED

52. TYPE OF BACKGROUND INVESTIGATION TO COMPLETE

Yes No Not applicable

SAC

NAC

NACI

CNACI

NACIC

NACLC

ANACI

MBI

LBI

BI

SSBI

SSBI-PR

53. FBI FINGERPRINT CHECK RESULTS

RECEIVED (mm/dd/yyyy)

REGISTRAR INFORMATION

57. NAME (Last, First, Middle)

58. REGISTRAR ID NUMBER

54. FAVORABLE RESULTS?

Yes No

55. BACKGROUND INVESTIGATION

COMPLETED (mm/dd/yyyy)

56. COMMENTS

59. REGISTRAR SIGNATURE 60. DATE (mm/dd/yyyy)

I hereby Approve Disapprove issuance of an HHS ID Badge to the above-named Applicant. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifiable information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

E. HHS ID Badge Details (To be completed by Issuer, after Section D has been completed)

61. NAME ON ID

BADGE ISSUER INFORMATION

64. NAME (Last, First, Middle)

65. ISSUER ID NUMBER

62. ID BADGE

NUMBER

63. ID BADGE EXPIRATION

DATE (mm/dd/yyyy)

I confirm that the (1) ID Badge Request received from the Sponsor is valid, and (2) approval notification received from the Registrar is valid.

I have verified that the individual collecting the ID Badge is the Applicant and have issued the ID Badge to the Applicant.

I have mailed the ID Badge and this form to in Remote Office on this date (mm/dd/yyyy) .

66. ISSUER SIGNATURE 67. DATE (mm/dd/yyyy)

I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifiable information, and/ or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

FOR REMOTE ISSUERS I have verified that the individual collecting the ID Badge is the Applicant and have issued the ID Badge to the Applicant.

68. REMOTE ISSUER NAME (Last, First, Middle) 69. REMOTE ISSUER ID

70. REMOTE ISSUER SIGNATURE 71. DATE (mm/dd/yyyy)

72. APPLICANT SIGNATURE 73. DATE (mm/dd/yyyy)

I have read and understand the Privacy Act Statement and HHS ID Badge Rules that were given to me. I accept the HHS ID Badge and agree to abide by the HHS ID Badge Rules.

F. Applicant Acknowledgement (To be completed by Applicant, after Section E has been completed)

HHS-745 (5/07) Page 4

Privacy Act Statement (Applicant Copy)

The information on this form is collected by the Department of Health and Human Services (HHS) to issue you an identification badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of government buildings, the people who work in them, and government computer systems. When you use your ID Badge an ID Badge system will verify that you are authorized to use government facilities. The system also will track and control the ID Badges that are issued. The authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal Facilities, June 28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social Security number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying your identity to process this application.

The information on this form may be disclosed only with your written consent, except where permitted by the Privacy Act. The disclosures permitted by the Privacy Act include disclosure to:

the Department of Justice, a court, or other government officials when the records are relevant and necessary to a law suit; the appropriate public authority (Federal, foreign, State, local, tribal, or otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation; a Member of Congress or congressional staff member at your written request; the National Archives and Records Administration for records management inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to do agency work and who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide whether to retain an employee, continue a security clearance, or agree to a contract, grant, license or benefi t; Federal, State, or local agencies, entities, individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Office of Management and Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is no longer valid.

If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will not have access to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the information may prevent you from being able to work.

HHS-745 (5/07) Page 5

Department of Health and Human services (HHS) ID Badge Rules (Applicant Copy)

The rules associated with the HHS ID Badge include but are not limited to

• Do not attempt to clone, modify, or obtain data from any HHS ID Badge.

• Protect and safeguard your ID Badge.

• If your ID Badge is lost or stolen, you must report the missing ID Badge within 24 hours of noting its disappearance. Your ID Badge will be disabled and you will have to apply for a replacement.

• If you become aware of any violation of these requirements or suspect that your ID Badge may have been used by someone else, immediately report that information to your agency's ID Badge issuing authority.

• You must request a new ID Badge within 30 days in the event of any change which may affect the ability to determine that you are the individual associated with the ID Badge (e.g., name change). You will provide documentation showing the reason for any such change where applicable.

• As part of the HHS exit process, you are to return your ID Badge to the designated official at your agency on your last day of employment at HHS or at the expiration of your authorized access to HHS facilities and/or IT systems.

• Do not attempt to assist others in gaining unauthorized access to Federal facilities or information. Accept responsibility for the whereabouts and conduct of any and all persons whom you have signed in (i.e., authorized admittance) to HHS facilities. All persons signed into HHS facilities are considered visitors.

Only visitor badges will be issued.

• Do not disclose or lend your identification number and/or password to someone else to gain access to HHS IT systems. They are for your use only and serve as your electronic signature. This means that you may be held responsible for the consequences of unauthorized access or illegal transactions.

HHS- 745.indd wwragg D:20071214174737Z D:20071214124839- 05'00'

HHS-745 (5/07)

H H S -7 45 (5/0 7) Page i Applicant Instructions for Completing Form HHS-745, "HHS ID Badge Request" Applicant Instructions for Completing Form H H S - 7 45, "H H S ID Badge Request".

Section A collects identifying information about Applicants needed to issue an HHS ID Badge. In some Federal agencies, Sponsors or other authorized officials will complete this section for Applicants. If you are an Applicant and are asked to complete Section A, follow the instructions below. During the ID Badge issuing process, you also will be asked to complete Section F.

Section eh collects identifying information about Applicants needed to issue an H H S ID Badge. In some Federal agencies, Sponsors or other authorized officials will complete this section for Applicants. If you are an Applicant and are asked to complete Section eh, follow the instructions below. During the I D Badge issuing process, you also will be asked to complete Section F.

Clearly print all information except for your signature.

Section A Section eh.

1.

Check the appropriate box to indicate why a new HHS ID Badge is being issued. If you check "Other," please indicate the reason in the space provided.

Check the appropriate box to indicate why a new H H S I D Badge is being issued. If you check "Other," please indicate the reason in the space provided.

2.

Enter your full legal name on the first line. If you have used other name(s), enter these names on the "Other Name(s) Used" line.

3.

Enter your date of birth in mm/dd/yyyy format.

Enter your date of birth in 2 digit month/ 2 digit day/ 4 digit year format.

4.

Enter your place of birth (city and state if born in the U.S. or city and country if foreign born).

Enter your place of birth (city and state if born in the U S or city and country if foreign born).

5.

Enter your Social Security Number (xxx-xx-xxxx).

6.

Check whether you are a U.S. citizen. If you are not a U.S. citizen, enter the country where you are a citizen.

Check whether you are a U S citizen. If you are not a U S citizen, enter the country where you are a citizen.

7.

Enter your position title (include series and grade level).

8.

Enter where you will be working. This could include the center, office, group, division, or institute. If you are a contractor Applicant, enter the organizational chain for the COTR's or Project Officer's division.

Enter where you will be working. This could include the center, office, group, division, or institute. If you are a contractor Applicant, enter the organizational chain for the C O T R's or Project Officer's division.

9.

Enter the physical location (building and office) of your office, work area, or contract office.

10.

Enter your work telephone number. If none, then list Contract Officer's, COTR's, or Project Officer's telephone number.

Enter your work telephone number. If none, then list Contract Officer's, C O T R's, or Project Officer's telephone number.

11.

Enter your email address.

Contractors and others employed outside the Federal government, complete items 12 through 14.

12.

Enter your company's name.

13.

Enter your company's address.

14.

Enter your company's telephone number.

All Applicants complete items 15 and 16.

15.

Sign to authorize HHS to conduct the identity proofing/verification process and to certify that you understand that actions may be taken against you if you provide false information on this form.

Sign to authorize H H S to conduct the identity proofing / verification process and to certify that you understand that actions may be taken against you if you provide false information on this form.

16.

Enter the date you signed.

Sections B, C, D, and E will be completed by HHS.

Sections B, C, D, and E will be completed by H H S.

Section F You will be given a copy of the Privacy Act Statement for this HHS ID Badge Request form and HHS ID Badge Rules.

You will be given a copy of the Privacy Act Statement for this H H S I D Badge Request form and H H S I D Badge Rules.

72.

Sign your name to certify that you have read and understand the Privacy Act Statement and HHS ID Badge Rules and that you agree to follow the HHS ID Badge rules.

73.

Enter the date of your signature.

This page deliberately left blank.

HHS-745 (5/07)

H H S-7 45 (5/07) PSC Graphics (301) 443-1090 PSC Graphics (3 0 1) 4 4 3-1 0 9 0

EF

E F.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Department of Health and Human Services (HHS) identification (ID) Badge Request (Other Federal Departments may call this type of ID badge a Personal Identity Verifi cation [PIV] card)

HHS ID BADGE ISSUING FACILITY IDENTIFICATION NUMBER

Privacy Act Statement: The information on this form is collected by the Department of Health and Human Services (HHS) to issue you an identification badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of government buildings, the people who work in them, and government computer systems. When you use your ID Badge an ID Badge system will verify that you are authorized to use government facilities. The system also will track and control the ID Badges that are issued. The authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal Facilities, June 28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social Security number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying your identity to process this application. The information on this form may be disclosed only with your written consent, except where permitted by the Privacy Act. The disclosures permitted by the Privacy Act include disclosure to: the Department of Justice, a court, or other government officials when the records are relevant and necessary to a law suit; the appropriate public authority (Federal, foreign, State, local, tribal, or otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation; a Member of Congress or congressional staff member at your written request; the National Archives and Records Administration for records management inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to do agency work and who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide whether to retain an employee, continue a security clearance, or agree to a contract, grant, license or benefi t; Federal, State, or local agencies, entities, individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Office of Management and Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is no longer valid. If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will not have access to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the information may prevent you from being able to work.

A. Applicant Information (To be completed by Applicant, Sponsor, or Authorized Official) 1.

REASON FOR ISSUANCE

New Application Renewal Lost Stolen Damaged Expired Other (specify):

2.

NAME (Last, First, Middle)

OTHER NAME(S) USED

3.

DATE OF BIRTH (mm/dd/yyyy) 4.

PLACE OF BIRTH

5.

SOCIAL SECURITY NUMBER (xxx-xx-xxxx) City State or Province Country 6.

U.S. CITIZEN

Yes No (specify citizenship):

7.

POSITION TITLE

8.

AGENCY / DIVISION

9.

BUILDING / OFFICE ADDRESS

10.

WORK PHONE

11.

EMAIL

E Mail.

For Contractors, complete lines 12 through 14 12.

ORGANIZATION / COMPANY NAME

13.

ADDRESS OF ORGANIZATION / COMPANY

14.

TELEPHONE OF ORGANIZATION / COMPANY

To be completed by Applicant 15.

APPLICANT SIGNATURE

16.

DATE (mm/dd/yyyy) I hereby authorize the release of information in this application to appropriate Federal agencies for the purposes of processing this application and verifying my identity. I also acknowledge that if I knowingly provide or assist in the provision of false information or non-verifi able information, and/or I purposely omit information, it could result in loss of access to HHS facilities and IT systems and in disciplinary action including removal from Federal service or a Federal contract, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

HHS-745 (5/07)

H H S-7 4 5 (5/07) B. HHS ID Badge Request (To be completed by Sponsor, after Section A has been completed) H H S I D Badge Request (To be completed by Sponsor, after Section eh has been completed).

17. ID BADGE TYPE (choose ALL that apply) Foreign National HHS Employee Other Federal Employee:

Contractor Organizational Affiliate:

APPLICANT NAME

18.

EMERGENCY RESPONDER

Yes No For Contractors, complete lines 21 through 27 PROJECT OFFICER INFORMATION (if not Sponsor) 21.

NAME (Last, First, Middle) 22.

CENTER/OFFICE/GROUP/DIVISION

23.

POSITION TITLE

24.

WORK PHONE

25.

EMAIL

I certify that the above Applicant will be participating on the contract identified on this form.

26.

PROJECT OFFICER SIGNATURE

27.

DATE (mm/dd/yyyy)

SPONSOR INFORMATION

28.

NAME (Last, First, Middle) 29.

SPONSOR ID NUMBER (or complete lines 30-33) 30.

AGENCY/DIVISION

31.

POSITION TITLE

32.

WORK PHONE

33.

EMAIL

For Contractors, complete lines 34 - 36 34.

APPLICANT CONTRACT NO.

APPLICANT CONTRACT Number.

35.

CONTRACT START (mm/dd/yyyy) 36.

CONTRACT EXPIRATION (mm/dd/yyyy) 37.

SPONSOR SIGNATURE

38.

DATE (mm/dd/yyyy) I agree to sponsor the above Applicant for an HHS ID Badge and certify that the information provided in Sections A and B are complete and accurate to the best of my knowledge. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifi able information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service and I may be subject to prosecution under applicable Federal criminal and civil statutes.

C.

Identity Proofing (To be completed by Sponsor, Enrollment Official, or Registrar after Section B has been completed) If the Applicant does not require a background investigation and is in possession of an undamaged, uncompromised, unexpired HHS ID Badge, you may complete all of Section C or only complete items 41-42 and 49-50.

39.

COPIES OF ID SOURCE DOCUMENTS ATTACHED?

Yes No 40.

DID APPLICANT PRESENT TWO FORMS OF IDENTIFICATION, ONE OF WHICH WAS A PHOTO ID ISSUED BY A STATE OR THE FEDERAL GOVERNMENT?

Yes No

IDENTITY PROOFER INFORMATION

41.

NAME (LAST, FIRST, MIDDLE)

42.

IDENTITY PROOFER ID NUMBER

IDENTITY SOURCE DOCUMENT TWO

46.

NAME

47.

DOC. TITLE

48.

DOC. EXPIRATION DATE (mm/dd/yyyy)

IDENTITY SOURCE DOCUMENT ONE

43.

NAME

44.

DOC. TITLE

45.

DOC. EXPIRATION DATE (mm/dd/yyyy) 49.

ID PROOFER SIGNATURE

50.

DATE (mm/dd/yyyy) I certify that the above Applicant appeared before me and presented two ID source documents, which to the best of my knowledge appeared to be genuine, or presented an undamaged uncompromised, unexpired HHS ID Badge and does not require a background investigation. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non- verifiable information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

Non-Sensitive (1) National Security/Secret or Confidential (2) National Security/Top Secret (3) National Security/Top Secret - SCI (4) Public Trust/Moderate Risk (5) Public Trust/High Risk (6) 19.

POSITION SENSITIVITY LEVEL

20.

ID BADGE EXPIRATION DATE

(mm/dd/yyyy)

HHS-745 (5/07)

H H S-7 4 5 (5/07) D.

HHS ID Badge Approval (To be completed by Registrar, after Section C has been completed) H H S I D Badge Approval (To be completed by Registrar, after Section C has been completed) If the Applicant does not require a background investigation and is in possession of an undamaged, uncompromised, unexpired HHS ID Badge, you may complete all of Section D or only complete items 51 and 57-60.

APPLICANT NAME

51.

RECIPROCITY VERIFIED (if applicable) PIPS RECORD ATTACHED 52.

TYPE OF BACKGROUND INVESTIGATION TO COMPLETE

Yes No Not applicable

SAC

NAC

NACI

CNACI

NACIC

NACLC

ANACI

MBI

LBI

BI

SSBI

SSBI-PR

53.

FBI FINGERPRINT CHECK RESULTS RECEIVED (mm/dd/yyyy)

REGISTRAR INFORMATION

57.

NAME (Last, First, Middle) 58.

REGISTRAR ID NUMBER

54.

FAVORABLE RESULTS?

Yes No 55.

BACKGROUND INVESTIGATION COMPLETED (mm/dd/yyyy) 56.

COMMENTS

59.

REGISTRAR SIGNATURE

60.

DATE (mm/dd/yyyy) I hereby Approve Disapprove issuance of an HHS ID Badge to the above-named Applicant. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifiable information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

E.

HHS ID Badge Details (To be completed by Issuer, after Section D has been completed) 61.

NAME ON ID BADGE

ISSUER INFORMATION

64.

NAME (Last, First, Middle) 65.

ISSUER ID NUMBER

62.

ID BADGE NUMBER

63.

ID BADGE EXPIRATION DATE (mm/dd/yyyy) I confirm that the (1) ID Badge Request received from the Sponsor is valid, and (2) approval notification received from the Registrar is valid.

I confirm that the (1) ID Badge Request received from the Sponsor is valid, and (2) approval notification received from the Registrar is valid.

If you confirm that the (1) ID Badge Request received from the Sponsor is valid, and (2) approval notification received from the Registrar is valid, please check this box by pressing the space bar or number pad slash key.

I have verified that the individual collecting the ID Badge is the Applicant and have issued the ID Badge to the Applicant.

I have mailed the ID Badge and this form to in Remote Office on this date (mm/dd/yyyy) 66.

ISSUER SIGNATURE

67.

DATE (mm/dd/yyyy) I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifiable information, and/ or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

FOR REMOTE ISSUERS

I have verified that the individual collecting the ID Badge is the Applicant and have issued the ID Badge to the Applicant.

68.

REMOTE ISSUER NAME (Last, First, Middle) 69.

REMOTE ISSUER ID

70.

REMOTE ISSUER SIGNATURE

71.

DATE (mm/dd/yyyy) 72.

APPLICANT SIGNATURE

73.

DATE (mm/dd/yyyy) I have read and understand the Privacy Act Statement and HHS ID Badge Rules that were given to me. I accept the HHS ID Badge and agree to abide by the HHS ID Badge Rules.

F.

Applicant Acknowledgement (To be completed by Applicant, after Section E has been completed)

HHS-745 (5/07)

H H S-7 4 5 (5/07) Privacy Act Statement (Applicant Copy) The information on this form is collected by the Department of Health and Human Services (HHS) to issue you an identification badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of government buildings, the people who work in them, and government computer systems. When you use your ID Badge an ID Badge system will verify that you are authorized to use government facilities. The system also will track and control the ID Badges that are issued. The authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal Facilities, June 28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social Security number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying your identity to process this application.

The information on this form may be disclosed only with your written consent, except where permitted by the Privacy Act. The disclosures permitted by the Privacy Act include disclosure to: the Department of Justice, a court, or other government officials when the records are relevant and necessary to a law suit; the appropriate public authority (Federal, foreign, State, local, tribal, or otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation; a Member of Congress or congressional staff member at your written request; the National Archives and Records Administration for records management inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to do agency work and who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide whether to retain an employee, continue a security clearance, or agree to a contract, grant, license or benefi t; Federal, State, or local agencies, entities, individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Office of Management and Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is no longer valid.

If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will not have access to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the information may prevent you from being able to work.

HHS-745 (5/07)

H H S-7 4 5 (5/07) Department of Health and Human services (HHS) ID Badge Rules (Applicant Copy) Department of Health and Human services (H H S) I D Badge Rules (Applicant Copy) The rules associated with the HHS ID Badge include but are not limited to The rules associated with the H H S I D Badge include but are not limited to Do not attempt to clone, modify, or obtain data from any HHS ID Badge.

Protect and safeguard your ID Badge.

If your ID Badge is lost or stolen, you must report the missing ID Badge within 24 hours of noting its disappearance. Your ID Badge will be disabled and you will have to apply for a replacement.

If you become aware of any violation of these requirements or suspect that your ID Badge may have been used by someone else, immediately report that information to your agency's ID Badge issuing authority.

You must request a new ID Badge within 30 days in the event of any change which may affect the ability to determine that you are the individual associated with the ID Badge (e.g., name change). You will provide documentation showing the reason for any such change where applicable.

As part of the HHS exit process, you are to return your ID Badge to the designated official at your agency on your last day of employment at HHS or at the expiration of your authorized access to HHS facilities and/or IT systems.

Do not attempt to assist others in gaining unauthorized access to Federal facilities or information. Accept responsibility for the whereabouts and conduct of any and all persons whom you have signed in (i.e., authorized admittance) to HHS facilities. All persons signed into HHS facilities are considered visitors. Only visitor badges will be issued.

Do not disclose or lend your identification number and/or password to someone else to gain access to HHS IT systems. They are for your use only and serve as your electronic signature. This means that you may be held responsible for the consequences of unauthorized access or illegal transactions.