36C25719Q1135-017.pdf

Department of Veterans Affairs VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

CONTRACT SECURITY SERVICES REQUEST - INSTRUCTIONAL FORM 1A

Purpose: The Contract Security Services Request is submitted to VSC to initiate the contract security verification process. By submitting this form, our office will ensure that each individual listed have been fingerprinted, the fingerprints are adjudicated if necessary, background investigations are initiated or existing background investigations are current and PIV badges are managed and sponsored. This form should be completed and signed by the contracting officer. Please refer to the instructions below when completing the Contract Security Services Request Form #1.

A Contracting Officer & Phone: Please provide the post-award contracting officer handling this contract and their phone number.

B COR (COTR) Name & Phone: Please list the Contracting Officer Representative (previously the Contracting Officer Technical Representative) and phone number. The COR is the liaison between the contracting officer and contracted company.

C Contract End Date: Please list the date in which the contract ends including all options to extend (for PIV badge expiration).

D SAO Region: Please list the Service Area Office in which the contracting officer is associated with (East, West or Central).

E Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station.

Should the task order number change at fiscal year end, please indicate on any future requests by listing the old task order number in parenthesis next to the new task number.

F Contractor Position Description: Please provide a position title for all individuals (ex: physician, consultant, electrician).

G Investigation Level: Please indicate the background security requirements as provided by the PDAT (Position Description Automated Tool). This would include background screening (SAC), low-level investigation (NACI), moderate-level investigation (MBI) and high-level investigation (BI). Please note that non-PIV badges (contract under 180-days) require at minimum a SAC, full PIV badges (over 180-days) require at minimum a NACI.

H Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

I Contractor Address: Please provide the contracting company address. This information is required for the Little Rock SIC investigation request.

J Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information.

This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

K Contractor POC Email: Please provide the email address for the above mentioned point-of-contact. This email will be included in the investigation request submitted to Little Rock SIC.

L Contracting Officer Signature: All requests must be signed by the contracting officer/specialist. This signature verifies that an official contract is in place prior to processing the applicants for investigation and badging.

M Station Number: Please indicate the facility station number where the work is being performed/facility to be billed.

N Network Access: Please indicate whether the individuals will be obtaining network access.

O Employee Name: Please provide the full legal name of the individuals working on this task order.

P SSN: Please provide complete social security numbers for all individuals listed.

Q Email Address: Please provide a valid email address for all individuals.

R DOB: Please provide date of birth for all individuals listed.

S Place of Birth: Please provide place of birth for all individuals listed, including city, state and country (if outside US). For foreign-born individuals, please provide proof of citizenship.

Revised Form April 2012

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACT SECURITY SERVICES REQUEST FORM #1A

(Please see Instructional Form 1a for assistance in completing this form)

New Request Addition

CONTRACTOR INFORMATION

A VA Contracting Officer Name & Phone:

B COTR Name & Phone:

C Contract End Date (Including Options):

D SAO Region (East/West/Central):

E Purchase/Task Order Number:

F Contractor Position Description: M Station #:

G Investigation Level (SAC/Low/Moderate/High): N Network Access (Y/N):

H Contract Company Name (Subcontractor):

I Contract Company Address:

J Contractor POC Name & Phone:

K Contractor POC Email:

L Contracting Officer Signature:

***This signature verifies that an official contract is in place prior to processing the applicants for badging***

O P Q R S

*Please use Supplemental Form 1b for additional individuals

CONTRACTOR EMPLOYEE INFORMATION

Employee Name

(Full Legal Name) SSN Email Address D.O.B.

Place of Birth (City, State/Country)

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACTOR / EMPLOYEE FINGERPRINT REQUEST INSTRUCTIONAL FORM 2A

Purpose: The Contractor/Employee Fingerprint Request is to assist individuals in obtaining fingerprinting services from VA Facilities nationwide, on behalf of the VSC. This form is required by Little Rock SIC before a request for investigation can be submitted.

A Full Legal Name: Please provide full legal name of individual requiring fingerprints.

B SSN Last Four: Please provide the last four of the individual’s social security number.

C Contractor (Yes/No): Please indicate whether the individual is a contractor. Contracted employees are considered contractors.

D VAMC Location: Please provide the name and location of the VA Facility where the fingerprints were submitted.

E Station Number: Please provide the station number of the VA Facility where the fingerprints were submitted.

F Date Fingerprinted: Please provide the date that the fingerprints were submitted at the VA Facility.

G Method of Fingerprinting: Please indicate whether the fingerprints were submitted electronically or if manual fingerprints were submitted with ink and fingerprint card.

H Date Card Mail to OPM: If fingerprints were submitted manually, please provide the date the card was mailed to

IMPORTANT NOTE:

If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below. Delivery confirmation is recommended.

OPM Fingerprinting/SAC Team 1137 Branchton Rd Boyers, PA 16020

*All fields on the fingerprint card MUST be completed or the card will be destroyed.

SON: 955C SOI:VA08

IPAC/OPAC: 3600.1200

APPLICANT SIGNATURE

APPLICANT COMPLETE ADDRESS

DATE SIGNATURE OF OFFICIAL

EMPLOYER COMPLETE ADDRESS

CITIZENSHIP

SOC SEC #

LAST NAME FIRST NAME MIDDLE

SON: 955C SOI:VA08

IPAC/OPAC: 3600.1200

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200

(Please see Instructional Form #2a for assistance in completing this form)

** This form must be taken to the fingerprinting appointment **

EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor (Yes/No):

After fingerprints are captured, return this completed form to your CO/COR for submission to VSC

*If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below, with this form. All fields on the fingerprint card MUST be completed.

Please refer to Instructional Form #2a for an example of a completed fingerprint card. OPM will destroy all cards with incomplete fields. Delivery confirmation is recommended.

OPM Fingerprinting/SAC Team

1137 Branchton Rd Boyers, PA 16020

FACILITY INFORMATION

D VAMC Name & Location:

E Station Number:

F Date Fingerprinted:

G Method of Fingerprinting: Electronically / Manually

H Date Card Mailed to OPM*:

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

VHA SERVICE CENTER PIV SPONSORSHIP FORM #3

(Please see Instruction Form #3a for assistance in completing this form)

CONTRACTOR / EMPLOYEE INFORMATION

* All fields are mandatory except va.gov email *

A Full Legal Name (First Middle Last):

B Date of Birth (MM/DD/YYYY):

C Social Security Number:

D Citizenship: (US Citizen, Naturalized, Non-Citizen)

E Assigned Duty Station:

F Address of Assigned Duty Station:

G VA.GOV Email Address:

H Gender:

I Race:

J Height:

K Weight:

L Eye Color:

M Hair Color:

N Place of Birth (City, State, Country):

O Position Title:

P Contractor Company Name:

Q Company Address:

Self Certification of Continuous Service

I hereby certify that my break in service following my last investigation is indicated by the block checked below.

(Check one)

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than 2 years. (You are required to submit the OF 306, Declaration for

Federal Employment, with this form.)

My break in service is greater than 2 years or; I have never worked for the federal government.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

DEPARTMENT OF VETERANS AFFAIRS

AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)

STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE

I Authorize the Department of Veterans Affairs Security Office to obtain Credit Reports from the Credit Bureau and other Consumer Reporting Agencies, Collection Agencies, and Retail Business Establishments which hold financial and credit information.

The Security Office will not take adverse action against the subject of investigation, based in whole or in part upon the results of the credit report. Should adverse action occur, the VA will provide a copy of the report and a written description of the subject's rights as described by the FTC under Section 1681g (c)(3) of Title

15. Any information from the consumer report, in violation of any applicable equal employment opportunity law or regulation, will not be used in the adjudication of the investigation.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon the request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, Office of Security and Law Enforcement, only for the purposes of the adjudication and establishment of eligibility/security clearance.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.

SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED

OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)

CURRENT ADDRESS (Include Street, City, State, and ZIP Code)

VA FORM

MAY 1998 0710