GSA850-17_(Contractor_Information_Worksheet).pdf

1. Contract Employee Information - To Be Completed By Contractor Suffix Gender

Non-U.S. Citizens Only: Complete the following:

2. Contract Information - To be completed by GSA Requesting Official

GENERAL SERVICES ADMINISTRATION GSA 850 (REV. 6/2017)

CONTRACTOR INFORMATION WORKSHEET

(For Official Use Only)

OMB Control Number: 3090-0283 Expiration Date: 7/31/2019

Full Last Name(s) (Family) Full First Name (Given) Full Middle Name (or NMN if none)

Social Security Number Date of Birth Place of Birth (City) Place of Birth (Country)

Country

Place of Birth: U.S. State

U.S. State

Place of Birth: Mexico (State)/Canada (Province)

Mexico (State)/Canada (Province)

Home Street Address Street Address (Line 2)

Personal E-Mail AddressPhone Number (Work Cell) Phone Number (Work Number)

City

Prior Investigation Approximate Investigation Date Agency Adjudicated Prior Investigation

ZIP Code

U.S. Citizen

Position (Job) Title

U.S. Port of Entry City and State Date of Entry Less than 3 Years U.S. Resident Alien Registration Number

Company Name (Primary) Company Name (Subcontractor) If applicable Data Universal Numbering System (DUNS) Number

Contract Number Type Contract Start Date

Contract End Date

Has Option Years

Number of Option Years

Task Order (TO)/Delivery Order (DO) Number (Enter Contract Base Number if TO/DO is Not Applicable)

Company Point of Contact (POC) First Name

Alternate Company Point of Contact (POC) First Name

Alternate Point of Contact (POC) E-Mail Address

Alternate Point of Contact (POC) Phone Number (Work Number)

Alternate Company Point of Contact (POC) Last Name

Alternate Company Point of Contact (POC) First Name

Alternate Point of Contact (POC) E-Mail Address

Alternate Point of Contact (POC) Phone Number (Work Number)

Alternate Company Point of Contact (POC) Last Name

Alternate Company Point of Contact (POC) First Name

Alternate Point of Contact (POC) E-Mail Address

Alternate Point of Contact (POC) Phone Number (Work Number)

Alternate Company Point of Contact (POC) Last Name

Alternate Company Point of Contact (POC) First Name

Company Point of Contact (POC) Last Name

Alternate Company Point of Contact (POC) Last Name

Point of Contact (POC) E-Mail Address

Alternate Point of Contact (POC) E-Mail Address

Point of Contact (POC) Phone Number (Work Number)

Alternate Point of Contact (POC) Phone Number (Work Number)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0283. We estimate that it will take 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

Country of Citizenship

3. Reimbursable Work Authorizations (RWA) / Interagency Agreement (IAA) (If applicable) - To be completed by GSA Requesting Official

RWA/IAA Number Agency

4. Project/Work Location Information (Government site where contractor is working) - To be completed by GSA Requesting Official

OtherGSA Building Number (Building Number Search)

Contractor Type (Definitions on Page 2)

American Recovery and Reinvestment Act (ARRA) Long Term Contractor Major Sponsoring Organization Sponsoring Office Symbol GSA Region http://www.gsa.gov/portal/ext/html/site/hb/category/25431/hostUri/portal

GSA 850 (REV. 6/2017) BACK

Alternate Last Name

Is PM/COR/COAlternate Work Phone NumberAlternate E-Mail AddressMiddle Name or

(NMN) if none Alternate First NameAlternate Last Name

Is PM/COR/COAlternate Work Phone NumberAlternate E-Mail AddressMiddle Name or

(NMN) if none Alternate First NameAlternate Last Name

Is PM/COR/COAlternate Work Phone NumberAlternate E-Mail AddressMiddle Name or

(NMN) if none Alternate First NameAlternate Last Name

Alternate First Name Middle Name or (NMN) if none Alternate E-Mail Address Alternate Work

Phone Number Is PM/COR/CO

Is PM/COR/CO/ CSWork Phone NumberE-Mail AddressMiddle Name or (NMN) if noneFirst NameLast Name

6. GSA Requesting Official Information - To be completed by GSA Requesting Official

Homeland Security Presidential Directive (HSPD 12) Card Required?

Investigation Type Request Note: National Security positions are processed by GSA Personnel Security (CIS)

5. Type of Investigation Requested - To be completed by GSA Requesting Official

INSTRUCTIONS

Applicability of Contractor Information Worksheet:

Use this Contractor Information Worksheet for all GSA contractors, located at http://www.gsa.gov/forms.

Contractor Type Definitions (Any GSA Service or Office May be Associated with Building Support, Embedded Contractors):

Building Support: Building maintenance or construction support contractor Embedded: “Side-by-side” or white collar contractor providing business services, and may have staff-like access to GSA space and IT systems External: Does not access GSA building or IT systems but requires a check or investigation Child Care: Child care worker

GSA Region Options: Region 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, NCR (National Capital Region) (11), or CO (Central Office)

Transmitting the Contractor Information Worksheet:

Do not save completed forms on your workstation. Per GSA requirements:

If Personally Identifiable Information (PII) needs to be transmitted over the Internet, it must be sent using encryption methods defined in Chapter 5, Paragraph 7 of GSA Order CIO P 2100.1E GSA Information Technology (IT).

All passwords must be encrypted in storage.

All sensitive information, such as PII, as deemed by the data owner, which is transmitted outside the GSA firewall, must be encrypted.

Certified encryption modules must be used in accordance with FIPS PUB 140-2, “Security requirements for Cryptographic Modules.”

When using password generated encryption keys, a password of at least 8 characters with a combination of letters, numbers, and special characters is required. A password of at least 12 characters is recommended.

Systems implementing encryption must follow the key management procedures and processes documented in CIO IT Security Procedural guide 09-43, “Key Management.”

If PII needs to be e-mailed within the GSA network, please use Google Mail. For additional protection the information also can be encrypted as described in Chapter 5, Paragraph 7, of this IT security policy.

If PII needs to be sent by courier, printed, or faxed several steps should be taken. When sending PII by courier mark "signature required" when sending documents. This creates a paper trail in the event items are misplaced or lost. Don't let PII documents sit on a printer where unauthorized employees or contractors can have access to the information. When faxing information use a secure fax line. If one is not available, contact the office prior to faxing so they know information is coming and contact them after transmission to ensure they received it. For each event the best course of action is limit access of PII only to those individuals authorized to handle it, create a paper trail, and verify information reached its destination.

Submission Information:

Check with your GSA regional point of contact for instructions on how to submit the completed form.

Privacy Act Notice:

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by the Federal Property and Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; E.O. 9397. Disclosure of the information is voluntary. This form will be used as a means to prepare and issue a credential or pass. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit.

If the individual does not provide some or any part of the requested information, the employee will not be issued a credential and will not be allowed to enter a GSA-controlled building after normal hours or when the building is under security.

http://www.gsa.gov/forms

1. Contract Employee Information - To Be Completed By Contractor Non-U.S. Citizens Only: Complete the following:

2. Contract Information - To be completed by GSA Requesting Official

GENERAL SERVICES ADMINISTRATION

GSA 850 (REV. 6/2017)

CONTRACTOR INFORMATION WORKSHEET

(For Official Use Only) OMB Control Number: 3090-0283 Expiration Date: 7/31/2019 Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0283. We estimate that it will take 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

3. Reimbursable Work Authorizations (RWA) / Interagency Agreement (IAA) (If applicable) - To be completed by GSA Requesting Official

4. Project/Work Location Information (Government site where contractor is working) - To be completed by GSA Requesting Official

GSA 850 (REV. 6/2017) BACK

6. GSA Requesting Official Information - To be completed by GSA Requesting Official

5. Type of Investigation Requested - To be completed by GSA Requesting Official

INSTRUCTIONS

Applicability of Contractor Information Worksheet:

Use this Contractor Information Worksheet for all GSA contractors, located at http://www.gsa.gov/forms.

Contractor Type Definitions (Any GSA Service or Office May be Associated with Building Support, Embedded Contractors):

Building Support: Building maintenance or construction support contractor Embedded: “Side-by-side” or white collar contractor providing business services, and may have staff-like access to GSA space and IT systems External: Does not access GSA building or IT systems but requires a check or investigation Child Care: Child care worker GSA Region Options: Region 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, NCR (National Capital Region) (11), or CO (Central Office) Transmitting the Contractor Information Worksheet:

Do not save completed forms on your workstation. Per GSA requirements:

If Personally Identifiable Information (PII) needs to be transmitted over the Internet, it must be sent using encryption methods defined in Chapter 5, Paragraph 7 of GSA Order CIO P 2100.1E GSA Information Technology (IT).

All passwords must be encrypted in storage.

All sensitive information, such as PII, as deemed by the data owner, which is transmitted outside the GSA firewall, must be encrypted.

Certified encryption modules must be used in accordance with FIPS PUB 140-2, “Security requirements for Cryptographic Modules.”

When using password generated encryption keys, a password of at least 8 characters with a combination of letters, numbers, and special characters is required. A password of at least 12 characters is recommended.

Systems implementing encryption must follow the key management procedures and processes documented in CIO IT Security Procedural guide 09-43, “Key Management.”

If PII needs to be e-mailed within the GSA network, please use Google Mail. For additional protection the information also can be encrypted as described in Chapter 5, Paragraph 7, of this IT security policy.

If PII needs to be sent by courier, printed, or faxed several steps should be taken. When sending PII by courier mark "signature required" when sending documents. This creates a paper trail in the event items are misplaced or lost. Don't let PII documents sit on a printer where unauthorized employees or contractors can have access to the information. When faxing information use a secure fax line. If one is not available, contact the office prior to faxing so they know information is coming and contact them after transmission to ensure they received it. For each event the best course of action is limit access of PII only to those individuals authorized to handle it, create a paper trail, and verify information reached its destination.

Submission Information:

Check with your GSA regional point of contact for instructions on how to submit the completed form.

Privacy Act Notice:In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by the Federal Property and Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; E.O. 9397. Disclosure of the information is voluntary. This form will be used as a means to prepare and issue a credential or pass. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit. If the individual does not provide some or any part of the requested information, the employee will not be issued a credential and will not be allowed to enter a GSA-controlled building after normal hours or when the building is under security.

Temporary Contractor Information Worksheet AlbertoValladares Normal AlbertoValladares Microsoft Office Word

4/7/2009 2:29:00 PM

4/7/2009 4:23:00 PM

4/7/2009 4:23:00 PM

10173

GSA

92672 12034

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