CIW_Ver._4.0_-_HSPD-12_-FORM-BLANK.pdf

ARRA Temporary Contractors:

Complete GSA Form 850 instead of CIW

For Official Use Only Contractor Information Worksheet (CIW)

Version 4 (Updated 12/7/10) Pg. 1 of 2

Type Contractor (Definitions on Pg. 2)

ARRA Long Term Contractor

ARRA Temporary (Short Term) Contractors: Use GSA Form 850

Investigation Preference

(if option offered in region)

Priority (Option available for MBI / BI only)

Sponsoring Office Symbol

GSA Region (Options on Pg.2)

1. Contract Employee Information Name (Last/Family)

First (Given)

Middle (or NMN if none)

Suffix

Social Security #

Date of Birth

Place of Birth (POB): City

POB: State

Country

Sex

Home Address Street e-Mail

Address Street (line 2)

Phone Number (Day)

Phone Number (Cell)

City

State

Zip

Position (Job) Title

IT System Administrator

Prior Investigation

Investigation Date

Agency that Adjudicated Prior Investigation

U.S. Citizen

Non-U.S. Citizens Only: Port of Entry City and State

Date of Entry

Less than 3 Yrs.

U.S. Resident

Alien Registration #

Citizenship Country

2. Contact Information Company Name

Company is:

If Sub, Name of Prime

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

Contract Number Type

Contract Start Date

Contract End Date

Has Option Yrs.

Or End Date TBD

Company Point of Contact (POC) Name

POC Phone Number (Day)

POC Email Address

3. Project/Work Location Information (Government site where contractor is working) GSA Building Number

Building Name

Building Address

4. Type of Investigation Requested for: GSA Access Card

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

5. Requesting Official (Sponsor) Information Sponsor’s Name

Title

Is COR/COTR

Email Address

Phone Number (Day)

Date Forms Were Reviewed

Alternate POC and Phone Number or Comments

6. Personnel Security Office:

OPM PIPS Inv Status e-QIP Invitation # Date e-Mail Sent

[ ] Release Form

[ ] CER

[ ] Medical Release [ ] GSA Form3665

[ ] FD 258

[ ] CS Case

[ ] FD 258 RAP

[ ] Just

Date Received

[ ] Reviewed [ ] Scan/TIF

Date Sent to OPM

Suitability Decision Preliminary Date [ ] Unfavorable [ ] Favorable

Final Date [ ] Unfavorable [ ] Favorable

Notify Preliminary Decision [ ] Email: hspd12.security@gsa.gov [ ] Email: COTR/Requesting Official [ ] Email: Subject [ ] Email: Subject’s Company Notify Final Decision [ ] Email: hspd12.security@gsa.gov [ ] Email: COTR/Requesting Official [ ] Email: Subject [ ] Email: Subject’s Company

Contractor Information Worksheet

Instructions

Version 4 (Pg. 2 of 2)

Applicability of Contractor Information Worksheet Use this Contractor Information Worksheet for all GSA contractors except ARRA temporary contractors. For all ARRA temporary contractors, use the GSA Form 850 available at http://gsa.gov/forms.

How to Enable Macros if You Are Not Able to Enter Information or Select Options Electronically If you receive an option to enable macros when you open the file, select Enable Macros.

If you are not able to make selections or enter text on the form, please adjust your macros security settings. To adjust your settings, open the file. Click on Tools, then move your cursor to Macros, then select Security. On the Security window that appears, select Low, then click OK. Save the file to your workstation. When you reopen it, the form should work properly.

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).

o All passwords must be encrypted in storage.

o 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.”

o 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.

o 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, at a minimum Lotus Notes encryption is required.

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; 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 working hours or when the building is under security.

http://gsa.gov/forms