Attachment Form 2_Universal Fingerprint Request Form.pdf

UNIVERSAL FINGERPRINT REQUEST FORM

Document Number: VHACOPERSEC Advisory - 19-08

Date Issued: 03/21/2019 Document Owner: VHACOPERSEC

Revision History: 01

PURPOSE: To provide a fingerprint request form template to be used universally by all medical centers, for all employee types, to capture both local and courtesy fingerprint requests and results as well as all information needed to sponsor employees for their Personnel Identify Verification (PIV) credentials.

SCOPE: The attached form may be used by VHA facilities and should be universally accepted when presented for fingerprinting services. Note: Offices such as the VHA Service Center (VSC) and Security Investigations Center (SIC) may require additional information.

PROCESS: This fingerprint request form should be emailed to anyone requiring fingerprinting services. The body of the email will contain any required information including SOI and SON for courtesy requests. The form should be typed, printed out, and presented to receive fingerprinting services. Courtesy requestors must ensure that adequate documentation is available substantiating the request (email message can be used). HPTs are advised to submit a copy of the completed form to their gaining station.

1. REFERENCES: VHA Directive 0710: VHA Personnel Security and Suitability

Program, dated October 11, 2018.

2. RESCISSION: None

3. REVIEW: VHA’s Personnel Security Program Office (VHACOPERSEC) is responsible for reviewing this advisory on an as needed basis if updates are required.

4. CONTENT: Questions about the contents of this advisory should be directed to the

VHACO Personnel Security mailbox at VHACOPERSEC@va.gov.

ROLAND ORLANDO

VHA Personnel Security Program Manager

VETERANS HEALTH ADMINISTRATION

WORKFORCE MANAGEMENT AND CONSULTING (10A2A)

PERSONNEL SECURITY ADVISORY

Applicant Category: Check One

EMPLOYEE CONTRACTOR

HEALTH PROFESSONS TRAINEE

(VHA intern, resident, fellow, student)

AFFILIATE VOLUNTEER OTHER:

ENTER YOUR NAME EXACTLY AS IT APPEARS ON IDs

Name: (Last, First, Middle) Other Last Names Used

SSN (use of pseudo number is not permitted) Position Title Telephone #

Date of Birth: (mm/dd/yyyy) City/State and Country of Birth

E-Mail Address Country of Citizenship Dual Citizen?

VA Work Location Organization (VHA, VBA, NCA, VACO, etc.

Contractors Only: Company Name Company Address/Work Email

Health Professions Trainees Only: School Name Training Program

FINGERPRINT LOCATION FINGERPRINT DATE (mm/dd/yyyy) PREVIOUS VA PIV CARD HOLDER (Yes/No)

GENDER (M/F) HEIGHT (inches) WEIGHT (US pounds) HAIR COLOR EYE COLOR RACE/ETHNICITY

FINGERPRINT REQUEST FORM

Bring with you two (2) original IDs (Identity Source Documents) from the list below https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf

Complete all fields on this form to the best of your ability

Start Date

Courtesy Prints for another Facility:

Facility: _______________________________________

SOI# _______________

SON# ______________

Fingerprint Results Cleared: YES NO (Circle One) Date/Initials of Clearance: ___________________________________ https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf