(3) Sample CIW Form.docx

CONTRACTOR INFORMATION WORKSHEET

(For Official Use Only) OMB Control Number: 3090-0283 Expiration Date: 07/31/2019

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.

1. Contract Employee Information – To be completed by Contractor

Full Last Name(s) (Family) Click here to enter text.

Full First Name (Given) Click here to enter text.

Full Middle Name (or NMN if none) Click here to enter text.

Suffix Choose an item.

Gender Choose an item.

Social Security Number Click here to enter text.

Date of Birth Enter Date Of Birth POB: City Click here to enter text.

POB: Country Choose an item.

POB: U.S. State Choose an item.

POB: Mexico (State) /Canada (Province) Choose an item.

Home Address Street Click here to enter text.

Address Street (line 2) Click here to enter text.

City

Country Choose an item.

U.S. State Choose an item.

Mexico (State) /Canada (Province) Choose an item.

Zip Click here to enter text.

Phone Number (Work Cell) Click here to enter text.

Phone Number (Work Number) Click here to enter text.

Personal Email Click here to enter text.

Position (Job) Title Click here to enter text.

Prior Investigation Choose an item.

Approx. Investigation Date Click here to enter a date.

Agency Adjudicated Prior Investigation Click here to enter text.

U.S. Citizen Choose an item.

Non-US Citizens Only: Port of Entry, US City and State Click here to enter text.

Date of Entry Click here to enter a date.

Less than 3 Yrs. U.S. Resident Choose an item.

Alien Registration # Click here to enter text.

Citizenship Country Choose an item.

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

Company Name (Primary) Click here to enter text.

Company Name (Sub) (If Applicable) Click here to enter text.

Data Universal Numbering System (DUNS) Number:

Click here to enter text.

Task Order (TO)/Delivery Order (DO) Number (Enter Contract Base Number if TO / DO is Not Applicable) Click here to enter text.

Contract Number Type Task Order/Delivery Order Number Contract Start Date Click here to enter a date.

Contract End Date Click here to enter a date.

Has Option Yrs.

Choose an item.

# of Option Years Choose an item.

Company Point of Contact (POC) First Name Click here to enter text.

Company Point of Contact (POC) Last Name Click here to enter text.

POC Work Phone Number Click here to enter text.

POC Email Address Click here to enter text.

Alternate Company Point of Contact (POC) First Name Click here to enter text.

Alternate Company Point of Contact (POC) Last Name Click here to enter text.

Alternate POC Work Phone Click here to enter text.

Alternate POC Email Address Click here to enter text.

Alternate Company Point of Contact (POC) First Name Click here to enter text.

Alternate Company Point of Contact (POC) Last Name Click here to enter text.

Alternate POC Work Phone Click here to enter text.

Alternate POC Email Address Click here to enter text.

Alternate Company Point of Contact (POC) First Name Click here to enter text.

Alternate Company Point of Contact (POC) Last Name Click here to enter text.

Alternate POC Work Phone Click here to enter text.

Alternate POC Email Address Click here to enter text.

Alternate Company Point of Contact (POC) First Name Click here to enter text.

Alternate Company Point of Contact (POC) Last Name Click here to enter text.

Alternate POC Work Phone Click here to enter text.

Alternate POC Email Address Click here to enter text.

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

RWA/IAA Number Click here to enter text.

Agency

GSA

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

GSA Building Number (Building Number Search)

ID0025ZZ

Other Choose an item.

Type Contractor (Definitions on Pg. 2) Building Support ARRA Long Term Contractor Choose an item.

Sponsoring Major Org Choose an item.

Sponsoring Office Symbol Click here to enter text.

GSA Region

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

Investigation Type Request

SAC

Note: National Security positions are processed by GSA Personnel Security (CIS) HSPD-12 Card Required?

No

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

Last Name Dilworth First Name Jed Middle (or NMN if none) D Email Address jed.dilworth@gsa.gov Work Phone 208-334-9219 Is PM/COR/CO/CS

COR

Alternate Last Name

Alternate First Name Click here to enter text.

Middle (or NMN if none) Click here to enter text.

Alternate Email Click here to enter text.

Work Alternate Phone Click here to enter text.

Is PM/COR/CO

PM

Alternate Last Name

Alternate First Name Click here to enter text.

Middle (or NMN if none) Click here to enter text.

Alternate Email Click here to enter text.

Work Alternate Phone Click here to enter text.

Is PM/COR/CO

Alternate Last Name

Alternate First Name Click here to enter text.

Middle (or NMN if none) Click here to enter text.

Alternate Email Click here to enter text.

Work Alternate Phone Click here to enter text.

Is PM/COR/CO

Alternate Last Name

Alternate First Name Click here to enter text.

Middle (or NMN if none) Click here to enter text.

Alternate Email Click here to enter text.

Work Alternate Phone Click here to enter text.

Is PM/COR/CO

Instructions

Applicability of Contractor Information Worksheet Use this Contractor Information Worksheet for all GSA contractors.

Type Contractor 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, or CO

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 emailed within the GSA network, please use Google E-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.

GSA 850 (REV. 8/2016) BACK

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