4-HHS 745 (Revised 03.24).pdf

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 Verification [PIV] Card)

HHS-745 (03/24) Page 1 of 4 PSC Publishing Services (301) 443-6740 EF

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 benefit; 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 City ZIP Code State or Province Country

5. SOCIAL SECURITY NUMBER (XXX-XX-XXXX) 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

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-verifiable 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.

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