2.2 AD-1197.pdf

Personal Identity Verification (PIV) Request for USDA ID Badge Privacy Notice: Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine suitability for the issuance of USDA credentials. The information will be used to identify proof and register applicants as part of the Personal Identity Verification process. Providing this information is voluntary; however, failure to submit this information may result in denial of a USDA credential.

A. Source Document Confirmation (To be completed by HR)

1. Replacement Card? No Yes 1a. Reason for Replacement:

2. BI* Application Complete? Yes (required for new cards only) [*BI is a generic reference to all investigations for Federal employment purposes]

Federal Employee3. Compliant Badge:

Applicant Information

Affiliate

LE/Physical Security

Press Corps

Contractor

Foreign National

Temporary RetireeSite3a. Non-Compliant Badge: Expiration Date (mm/dd/yyyy):

4. Name:

9. Work Address:

7. Birth Date (mm/dd/yyyy):

13. Email:

14. Name:

Identity Source Document 1 (Attach copy)

15. Doc. #:

16. Doc. Title:

17. Issuer:

18. Doc. Expiration Date (mm/dd/yyyy):

5. Phone:

8. Organization:

10. City:

13a. Applicant SSN:

11. State: 12. ZIP Code:

6. Position:

19. Name:

Identity Source Document 2 (Attach copy)

20. Doc. #:

21. Doc. Title:

22. Issuer:

23. Doc. Expiration Date (mm/dd/yyyy):

B. PIV Credential Request (To be completed by Sponsor)

27a. Access Required:

27. Email:26. Organization:

25. Phone:24. Name:

Sponsor Information

I agree to sponsor the above application for a PIV credential and certify that the information is accurate to the best of my knowledge.

28.

PRINTED NAME OF SPONSOR SIGNATURE (mm/dd/yyyy)

29. DATE:

(To be completed by Registrar for new cards ONLY, after Sections A & B are completed)C. Issuance Approval

30. Date Completed (mm/dd/yyyy):

FBI Fingerprint Check/NAC Results

33. Name:

Registrar Information

Yes No31. Successfully adjudicated?

32. Comments:

36. Email:

34. Organization:

35. Phone:

I hereby certify that the information regarding the above applicant is accurate to the best of my knowledge.

I hereby approve do not approve this application for credential issuance.

38.

PRINTED NAME OF REGISTRAR SIGNATURE (mm/dd/yyyy)

39. DATE:

37.

Form AD-1197 (Sep 2005) OMB Control #: 0505-0022

This form was electronically produced by USDA/ARS/OCIO/ADB.

(mm/dd/yyyy)

48. DATE:

SIGNATUREPRINTED NAME OF ISSUER

47.

I hereby acknowledge issuance of a credential to the applicant identified above based on verification of the applicant's identity and verification of the above Registrar's issuance approval.

(To be completed by Issuer after Sections A, B [and C, if required] are completed)D. Credential Details

40. Name on Credential: 43. Name:

Issuer Information

41. Credential Identifier:

42. Credential Expiration Date (mm/dd/yyyy):

46. Email:

44. Organization:

45. Phone:

(To be completed by Applicant after Section D is completed)E. Applicant Acknowledgement

I, the Applicant, confirm receipt of the PIV credential identified above and hereby certify that the information is accurate to the best of my knowledge.

(mm/dd/yyyy)

50. DATE:

SIGNATUREPRINTED NAME OF APPLICANT

49.

Form AD-1197 (Sep 2005) OMB Control #: 0505-0022

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0505-0022. The time required to complete this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed and completing and reviewing the form. (e) Agency Requirements.--Each agency that maintains a system of records shall-- (1) maintain in its records only such information about an individual as is relevant and necessary to accomplish a purpose of the agency required to be accomplished by statute or by executive order of the President; (2) collect information to the greatest extent practicable directly from the subject individual when the information may result in adverse determinations about an individual's rights, benefits, and privileges under Federal programs; (3) inform each individual whom it asks to supply information, on the form which it uses to collect the information or on a separate form that can be retained by the individual-- (A) the authority (whether granted by statute, or by executive order of the President) which authorizes the solicitation of the information and whether disclosure of such information is mandatory or voluntary; (B) the principal purpose or purposes for which the information is intended to be used; (C) the routine uses which may be made of the information, as published pursuant to paragraph (4)(D) of this subsection; and (D) the effects on him, if any, of not providing all or any part of the requested information.

Form AD-1197 (Sep 2005)

13a. Applicant SSN

13. Email

9-12. Work Address, City, State, ZIP Code

8. Organization

7. Birth Date

6. Position

5. Phone

4. Name

3a. Non-Compliant Badge (if Temporary)

3. Compliant Badge (if Permanent)

Applicant Information

2. BI (Background Investigation) Application Complete?

1. Replacement Card?

Section A - Source Document Confirmation

Instructions for Completing the AD-1197 for New Employees This form is required for all first time Federal appointments. It is used to determine suitability for the issuance of USDA credentials.

The information will be used to identify proof and register applicants as part of the government-wide Personal Identity Verification process.

� Check "No"

� Check "Yes" if replacing badge due to extension of temporary appointment beyond NTE date.

Check "Yes" ONLY if we have received their SF-85 or SF-85P, or the employee has been initiated into eQIP for completing the SF-86

Check "Federal Employee"�

� Check "Temporary" and state the NTE date.

� A replacement badge will need to be issued if temporary appointment is extended beyond the NTE date (see #1 above).

Use employee's legal name as it appears on his/her Social Security card, driver's license, or passport.�

Obtain employee's work phone number from unit official prior to EOD.�

Use official position title.�

As stated.�

Name of REE Agency.�

Use work address ov employee; may need to obtain from unit official prior to EOD.�

Obtain from unit official prior to EOD.�

As stated.�

32. Comments

31. Successfully adjudicated?

30. Date Completed

Section C - Issuance Approval

29. Date

28. Name/Signature of Sponsor

27a. Access Required

27. Email

26. Organization

25. Phone

24. Name

Sponsor Information

Section B - PIV Credential Request

Identity Source Document 2 -

18. Document Expiration Date

17. Issuer

16. Document Title

15. Document Number

14. Name

Identity Source Document 1 - Attach a copy of any State of Federal photo ID as listed on Attachment A.

Attach a copy of any document from Attachment A.

19-23. Use the same process as noted above in steps 14-18 for identity Source Document 1.

Use employee's legal name as it appears on the source document.�

As stated on ID.� e.g., Minnesota Driver's License or USA Passport.� e.g., State of Minnesota or Secretary of State of USA�

As stated on ID.�

Director, selecting officials (or designee) responsible for Source Document verification.�

Phone number of individual listed in #24.�

Name of REE Agency.�

Email address of individual listed in #24.�

Long term access to Federally Controlled Facilities and/or Information Systems.�

Printed name and signature of Official listed in #24.�

Date of signature.�

NACI - Use "Closed" date on the Case Closing Transmittal.� Higher than NACI - Use date of SAC approval (as provided by HRS/HRA).�

Check "Yes."�

N/A.�

39. Date

38. Name/Signature of Registrar

37. Certification Statement

36. Email

35. Phone

34. Organization

33. Name

50. Date

49. Name and Signature of Applicant

Section E - Applicant Acknowledgement

48. Date

47. Name and Signature of Issuer

46. Email

45. Phone

44. Organization

43. Name

42. Credential Expiration Date

41. Credential Identifier

40. Name on Credential

Section D - Credential Details

Name of Human Resources Assistant (Information Systems) or Quality Assurance Specialist.�

Agricultural Research Service�

Phone number of Human Resources Assistant (Information Systems) or Quality Assurance Specialist.�

Email of Human Resources Assistant (Information Systems) or Quality Assurance Specialist.�

Check "Approve."�

Printed name and signature of Human Resources Assistant (Information Systems) or Quality Assurance Specialist.�

Date of signature.�

Date of signature.�

Date of signature.�

Printed name and signature of individual listed in #43.�

Printed name and signature of employee.�

New employee will complete this section upon receipt of PIV ID Badge.

Email address of individual listed in #43.�

Phone number of individual listed in #43.�

Use REE Agency name and specific organizational designation.�

Printed name of issuer of PIV ID badge.�

As stated on the source document presented.�

Title of the document presented, e.g., Maryland Driver's License.�

Use employee's legal name as it appears on his/her source document.�