Attachment_7,_Fitness-Security_Request_Form.pdf

Training Support Services

Attachment 7

Fitness/Security Screening Request Form

FEMA Form 121-3-1-6, 4/13

DEPARTMENT OF HOMELAND SECURITY

FEDERAL EMERGENCY MANAGEMENT AGENCY

CONTRACT FITNESS/SECURITY SCREENING REQUEST

Please refer to the instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to FEMA-OCSO-CONTRACTOR-COMPLIANCE-SECTION@FEMA.DHS.GOV by the CO, COR, or Federal POC.

Positions requiring SCI access must be reviewed and submitted by the Office/Directorate SSO

(FEMA-OCSO-SSO@DHS.FEMA.GOV).

Request Type: Please select the type of request

Section I: Requesting Official/Organization

Section II: Individual to be Screened

For UNCLASSIFIED CONTRACT'S, please complete Section III. Section III: Position Designation (Please CHECK ONLY ONE)

For CLASSIFIED CONTRACT'S, please complete Section IV. Section IV: Position Security Clearance Requirement (Please CHECK ONLY ONE)

Privacy Information AUTHORITY: 5USC 5701-5733, Sections 5701-5733 and Executive Order 9397. DISCLOSURE: Disclosure of information is voluntary.

PURPOSE: To identify the applicant precisely when processing the requested action.

(1) Denotes fields required for completing an Exit Request. This form must be submitted electronically to FEMA-OCSO-CONTRACTOR- COMPLIANCE-SECTION@FEMA.DHS.GOV by the CO, COR, or Federal POC.

Instructions: A DD-254 form is required for all contractor positions requiring a security clearance. By selecting “Yes” in the DD254 on File box below, you are verifying that a DD-254 is on file for the contract identified above. For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Applicants Full Name

Applicant Currently on Contract with DHS Components:

Non-IT Position Risk Level:

IT Position Risk Level:

Security Clearance Level: * Approved by SSO:

* 9 For Buildings Access ONLY - No Access to FEMA Systems/Information is Required)

If Yes, Please Indicate DHS Component:

Place of Birth

Contracting Officer (CO):

Prime Contractor: (1)

Name of Contracting Officer Rep (COR)/ Contracting Officer (CO) or Federal Point of Contact (POC): (1)

Date (mm/dd/yr)

Name of Contracting Officer (CO)

Name

Name

Last First Middle

Telephone Number

Telephone Number

Telephone Number

Prime Contract Number:

Applicant Position Title: (1)

Social Security Number (1) Date of Birth City Country (if not US)

Applicants E-Mail Address: Applicants Daytime Phone Number:

Begin Date (1) End Date (1)

Task Order Number FEMA Organization/Division Name: (1)

Gender

State

DD254 on File

New Request New Request (Reciprocity) Position Change

Contract Change Dual Change Name Change Exit Request (1)

Yes No

DHS HQ

USGC

CBP FEMA FLETC TSA

USSSUSICEUSCIS

Background Invest. Type-Date Investigative Agency Clearance Granted (If any) -Level & Date

Low Risk* Moderate Risk (5N) High Risk (6N)

Moderate Risk (5C) High Risk (6C)

Secret Top Secret SCI* Yes No

General

The FEMA Form 121-3-1-6, Contractor Fitness/Security Screening Request Form is used by FEMA federal employees to request that the Office of the Chief Security Officer, Personnel Security Division (PSD) perform the appropriate fitness screening on contractor employees based on the risk level of their position. The risk level is based on an overall assessment of the damage that an untrustworthy individual could cause to the efficiency or the integrity of FEMA operations. When determining risk levels, program officials may compare the individual's duties, responsibilities, and access with those of FEMA federal employees in similar positions.

The position designation is critical to the contractor fitness process in that it determines the investigative requirements associated with the position. For example, the minimum investigative standard for a Moderate Risk Public Trust position is a Minimum Background Investigation (MBI) conducted within the last 5 years. If during the fitness process it is determined that the individual has been investigated by another federal agency, FEMA may use that investigation(s) whenever practical. However, if the investigation is out of date (scope), or not at the required level for the position, FEMA will need to initiate a new or upgraded background investigation and incur the costs associated with the investigation.

On Classified Contracts a few or all positions may require access to national security information (NSI). In this case, the contractor employee must have an active clearance already in place prior to being permitted to perform on a FEMA contract. The clearance must meet or exceed the level designated by the FEMA position and must be visible in the JPAS Database.

FEMA does not sponsor National Security background investigations or grant security clearances to contract employees.

Contractor Employee Clearances - Please note that FEMA recognizes contract employee clearance levels based on the risk or access level designated to the FEMA contract position. For example, a contract employee may be eligible through their company and DISCO for access at the Top Secret level, however, if the FEMA contract position is designated at the Secret level, then the position and associated PIV card or badge is marked at the Secret level, not the Top Secret level. Using the same example, if the FEMA position is designated as a Public Trust position (i.e., unclassified contracts - low thru high risk), then the position and associated PIV card or badge is marked with no security clearance. Basically, the security clearance level is associated with the position working in, and not the individual.

Section - Request Type

Please enter the date of the request, and select at least one of the following request types:

New Request - Select “New Request” when the contractor employee is new to the Office or

Directorate.

New Request (Reciprocity) - Select "New Request (Reciprocity) when the contractor employee is new to the Office or Directorate and has the required investigative or Security Clearance for contract assignment and performance.

Position Change - Select “Position Change” when the duties of the contract position require a higher or lower level or access or risk (e.g., clearance upgrade/downgrade).

Contract Change - Select “Contract Change” if the contractor employee is changing contracts or is transferring from one Directorate to another.

Dual Contracts - Select “Dual Contract” if it is known in advance that the contractor employee is working on two or more contracts.

Name Change - Select “Name Change” if the contractor employee has legally changed their last name.

Exit Request - Select “Exit Request” if the contractor employee has left the contract position.

Please note that only those fields marked as (1) are required to be completed for an Exit request.

Section 1 - Requesting Official/Organization

Please complete all fields in Section I.

Section II - Individual to be Screened

Complete all fields in Section II.

Section III - Position Designation

Complete this section for positions associated with UNCLASSIFIED Contracts, or Classified contracts where the position requested does not require a Clearance. Only one risk level should be checked in either the Non-IT or IT Position area.

The following field definitions are provided to assist with the completion of this section:

Non-IT versus IT Positions

• Information Technology (IT) - Systems and services used in the automated acquisition, storage, manipulation, management, movement, control, display, switching, interchange, transmission, assurance, or reception of information. Information technology includes computers, network components, peripheral equipment, software, firmware, services, and related sources.

• Information Technology (IT) Position - Positions that manage, supervise, lead, administer, develop, deliver, or support information technology (IT) systems and services. Positions where the paramount requirement is knowledge of IT principles, concepts, and methods; e.g., data storage, software applications, and networking. (e.g., IT Worker)

• Non-Information Technology (IT) Position - Positions where the paramount requirement is the knowledge of other subject-matter principles, concepts, and methods. These positions may require the knowledge of the application of information technology to the assignment area or may require skill in use of IT software and hardware systems, but are not directly involved in development, delivering or supporting IT systems and services. (e.g., IT User)

Risk Levels

• Low Risk - Low Risk positions have the potential for limited impact on the integrity and efficiency of the service. These positions involve duties and responsibilities of limited relation to the agency or program mission.

o Please note that Low Risk is used for Building Access ONLY, where the position will not require access to FEMA systems or information.

• Moderate Risk (5N/5C) - Moderate Risk positions have the potential for moderate to serious impact on the integrity and efficiency of the service. These positions involve duties that are considerable important to the agency or program mission with significant program responsibility or delivery of service.

• High Risk (6N/6C) - High Risk positions have the potential for exceptionally serious impact on the integrity and efficiency of the service. These. These. These.These positions involve duties that are especially critical to the agency or the program mission with a broad scope of responsibility and authority.

Section IV - Position Security Clearance Requirements

Please complete this section for positions associated with CLASSIFIED Contracts. Please note that a DD-254 form is required for all contractor positions requiring a security clearance. By selecting “Yes” in the DD254 on File box below, you are verifying that a DD-254 is on file for the contract identified above. For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Important: Classified positions requiring access to Special Compartmented Information (SCI) must be pre-approved by the Office Directorate SSO prior to sending to the FEMA Personnel Security Division.

Electronic Transmittal of FEMA Form Important: FEMA Personnel Security Division (PSD) will only accept FEMA Form 121-3-1-6, forms submitted by FEMA's COs, COTRs, or Federal Points of Contact (POCs). FEMA Form 121-3-1-6, Forms submitted by Contractor Employees or Contractor Company representatives will not be processed.

1. Complete FEMA Form, Contract Fitness/Security Screening Request;

2. Password Protected the File;

a.To Password Protect the File - Go to Tools - Options and click on the Security tab.

b.Under File Encryption Options for this Document - enter a password in the “Password to Open” box, and click OK; enter the same password in the Confirm Password dialog box.

c.Upon saving and closing the form, the password provided will be required to open.

3. Save the File using the following file naming convention: Applicant Last Name Request Date (MM/DD/YYYY) (Example:

Smith12042008.xls)

-OR-

Scan the completed FEMA Contract Fitness/Security Screening Request to a PDF file format. Using software such as Adobe Professional, Password Protected; and Save the File using the following naming convention: Applicant Last Name Request Date.pdf (Example: Smith12042008.pdf)

4. E-mail the file as an attachment to FEMA-OCSO-CONTRACTOR-COMPLIANCE-SECTION@FEMA.DHS.GOV a Subject line of “FEMA Directorate - FEMA Form, Contract Fitness/Security Screening Request - Date (Example: OPO - FEMA Form, Contract Fitness/Security Screening Request - 12/04/2008)

5. In a second e-mail to FEMA-OCSO-CONTRACTOR-COMPLIANCE-SECTION@FEMA.DHS.GOV using the same Subject line, send the password used to protect the information contained in the attachments.

Note: Please create or scan only one FEMA Form, Contract Fitness/Security Screening Request within a file attachment. If sending multiple attachments in a single e-mail message, please use the same password for all attachments contained within the message.