SOW Appendix 6 - Contractor Background Investigation Request Form REV 02-04-2025.pdf
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- Solicitation number
- 36C77625B0014
About this file
The document is a Contractor Background Investigation Request form from the VA Personnel Security Adjudication Center, designed to collect comprehensive personal and company information for a contractor background investigation. The form requires mandatory completion of fields across four main sections: VA Organization Information, Individual Information, Company Information, and CO/COR (Contracting Officer/Contracting Officer's Representative) details. The form is associated with a VA construction project for Electronic Health Record Management (EHRM) Tier Two Infrastructure Upgrades at the Fargo VA Medical Center, with the solicitation number 36C77625B0014, and is to be uploaded to the PSAC Resource Site after completion. The version is dated February 4, 2025, and includes specific instructions such as leaving the state of birth blank if foreign-born and using semicolons for multiple email addresses.
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Text version
Contractor Background Investigation Request (All Fields Are Mandatory - Please Complete Entire Form)
VA Organization Information
Upload signed request to PSAC Resource Site.
version February 4, 2025
Printed/Distilled Copy
Only original can be submitted to PSAC.
https://dvagov.sharepoint.com/sites/LIT/vasic/default.aspx
| Station Label: Station # |
| Date Label: Current Date: |
| Date: |
| City Of Birth Label: City of Birth |
| Date of Birth Label: Date of Birth |
| Company POC Label: Company POC |
| Company POC Email Label: POC Email Address |
| Company City Label: City |
| Company Zip Label: Zip |
| Last Name: |
| Middle Name: |
| Company State: [ ] |
| First Name: |
| Company State Label: State |
| Last Name Label: Last Name |
| Middle Name Label: Middle Name |
| First Name Label: First Name |
| SSN Label: SSN |
| SSN: |
| Email Address: |
| Country of Citizenship: [ ] |
| Country Of Birth Label: Country of Birth |
| State of Birth Label: State of Birth |
| Country of Citizenship Label: Country of Citizenship |
| Position Title Label: Position Title |
| Company POC: |
| Position Title: |
| Priority Label: Priority |
| Child Care Label: Child Care |
| Priority: Off |
| Child Care: Off |
| Individual Information Label: Individual Information |
| Company Information Label: Company Information |
| COR Information: CO / COR |
| COR Name Label: Name of CO / COR |
| State of Birth: [ ] |
| Company Zip: |
| Company City: |
| Company POC Email: Use semicolons for multiple addresses. |
| COR Name: |
| Options Label: Additional options may be presented after an investigation is selected. |
If Contractor is Not a U.S. Citizen, Completion of the Foreign National Check Form is Also Required.
| Investigation Label: Investigation |
| Contractor Company Label: Contractor Company |
| Contractor Company: |
| Task Order Number Label: Task Order Number |
| Task Order Number: |
| POC Address Label: POC Address |
| POC Address: |
| Reinvestigation Label: Reinvestigation |
| Reinvestigation: Off |
| Include SAC Label: Include SAC (fingerprint report) |
| Include SAC: Off |
| Country of Birth: [ ] |
| State Instructions: Leave blank if foreign born. |
| City of Birth: |
| Date of Birth: |
| COR Email Label: CO / COR Email |
| COR Email: |
| Station: [ ] |
| Email Address Label: Email Address |
| Phone Number: |
| Contractor Phone Number: |
| Marital Status Label: Marital Status |
| Investigation: [Select One...] |
| Marital Status: [Select One...] |
| Phone Number Label: Phone Number |
| SPVO Label: Servicing Personnel |
Vetting Office (SPVO)
| Organization: [ ] |
| SPVO: [ --Select--] |
| Assigned Organization Label: VA Assigned |
Organization
| VA CO or COR Signature Label: VA CO or COR Signature Required |
| Additional Comments: Additional Comments: |
| Sex Label: Sex |
| Sex: |
File details come from the government source that posted it. Updated .