Attachment 6-DHS Form 11000-25.pdf

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Jeong, Esther (CTR) 11.0.0.20130303.1.892433 DHS Form 11000-25

CONTRACTOR FITNESS / SECURITY SCREENING REQUEST FORM

Section II: Applicant Information Please refer to the appended instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to by the CO, COTR, or Federal POC.

Section I: Requesting Official/Organization 1.

Date of Submission 2.

DHS Organization 3.

Type of Request 4.

Exit Request Reason 5a.

CO:

Phone DHS Email 5b. COTR/Federal POC:

Phone DHS Email 6.

Prime Contractor

7. Prime Contract No.

8.

Task Order No.

9.

PIV Required 10.

DHS Organization Structure Code 11.

Applicant Name 12.

Position Title 13.

SSN

14.

Gender 15.

Place of Birth 16.

Date of Birth 17.

U.S. Citizen 18.

Phone

19. Email Section III: Position Designation 20.

Position Risk Level Section IV: Position Security Clearance Requirement 21.

Security Clearance Level 22.

DD254 on File Privacy Act Information Authority: 5 U.S.C. 5701-5733, Sections 5701-5733 and Executive Order 9397. Purpose: To facilitate the screening of applicants for contractor positions. Disclosure: Participation is voluntary; however, failure to provide this information may delay processing.

1 Indicates fields required for completing an Exit Request.

Last First Middle City State Country (if not U.S.)

Name Name Last First Last First

UNCLASSIFIED//FOR OFFICIAL USE ONLY

Complete this section for UNCLASSIFIED CONTRACTS ONLY. Note: Low Risk is used for Building Access ONLY, where the position will not require access to DHS systems or information.

Complete this section for CLASSIFIED CONTRACTS ONLY. Note: A DD254 form is required for all contractor positions requiring a security clearance, and should be on file with ISPB.

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR FITNESS/SECURITY SCREENING REQUEST FORM

DHS Form 11000-25 (7/17) Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request General The DHS form 11000.25, Contractor Fitness/Security Screening Request is used by DHS federal employees to request that the Office of Security, Personnel Security Division (PSD) perform the appropriate fitness screening on contract employees based on the risk levels of their positions. 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 DHS operations. When determining risk levels, program officials may compare the individual’s duties, responsibilities, and access with those of DHS 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 Tier-2 investigation conducted within the last 5 years. If, during the fitness process, it is determined that the individual has been investigated by another Federal agency, DHS will use the investigation(s) whenever practical. However, if the investigation is out of date or not at the required level for the position, DHS will need to initiate a new background investigation and incur the costs associated with the investigation. Therefore, it is extremely important that the appropriate position designation be made on the initial request to avoid the additional cost and time associated with position changes that may require higher level investigations.

On Classified Contracts, a few or all of the positions may require access to national security information (NSI). In this case, the contract employee must have an active clearance at, or higher than, the level designated by the DHS position. Please note that DHS does not grant security clearances to contract employees.

Contract Employee Clearances - DHS recognizes contract employee clearance levels based on the risk or access level designated to the DHS contract position. For example, a contract employee may be eligible through his company and the Department of Defense Consolidated Adjudications Facility (DoD CAF) for access at the Top Secret level; however, if the DHS 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 DHS position is designated as a Public Trust position (i.e., unclassified contracts – low through high risk), then the position and associated PIV card or badge is marked with no security clearance. In other words, the security clearance level is to be associated with the position, and not the individual.

Section I: Requesting Official/Organization Please complete all fields in Section I.

For 3. Type of Request, select one of the following request types:

Contract Change – Select if the contract employee is changing contracts or is transferring from one Directorate to another.

w Exit Request – Select if the contract employee has left the contract position.

Please note that only those fields marked with 1 are required to be completed for an Exit Request.

o w w w w w w w Multiple Contracts – Select if it is known in advance that the contract employee is working on two or more contracts.

Name Change – Select if the contract employee has legally changed his/her last name.

New Request – Select if the contract employee is new to the Office or Directorate.

Position Change – Select if the duties of the contract position require a higher or lower level of access or risk (e.g., clearance upgrade/downgrade; TECS access upgrade/downgrade).

Reinvestigation – Select if one of the following conditions apply:

a.

Contract employee has an investigation that was completed after the date of submission of the last 11000.25 form.

Important: If there is an investigation that was recently updated, the submitter of the current 11000.25 form must provide proof of the completed investigation.

b.

Contract employee requires an updated investigation to be initiated by the Security Office.

Temporary Position – Select if the contract employee will be on the contract for 180 days or less.

DHS Form 11000-25 (7/17) Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request The following definition is provided to assist with the completion of this section:

DHS Organization Structure Code – The DHS Organization Structure Code is the 18-digit code used by DHS to identify the Division sponsoring the request. If you are not sure of the code for your organization, please contact your Human Resource Liaison.

Section II: Applicant Information Please complete all fields in Section II.

Section III: Position Designation Please 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 selected in either the Non-IT or IT Position category.

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 (N) – 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 DHS 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 of considerable importance 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 positions involve duties that are especially critical to the agency or the program mission with a broad scope of responsibility and authority.

DHS Form 11000-25 (7/17) Section IV: Position Security Clearance Requirement 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, and must be on file with the DHS Industrial Security Program Branch (ISPB). For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Important: By selecting the DD254 on File checkbox, you are verifying that a DD-254 is on file for the contract identified above. To verify DD254 information, please contact DD254administrativesecurity@hq.dhs.gov.

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request Electronic Transmittal of DHS Form 11000.25 Important: DHS Personnel Security Division (PSD) will only accept DHS 11000.25 forms submitted by DHS Contracting Officer Representatives (CORs) or Federal Points of Contact (POCs). DHS 11000.25 forms submitted electronically by Contract Employees or Contractor Company representatives will not be processed.

1) Complete the DHS Form 11000.25, Contractor Fitness/Security Screening Request;

2) Scan the file (if applicable);

3) Password-Protect the File;

a.

To password-protect the file, go to Tools – Protect & Standardize and click on the Protect icon.

b.

Expand the Encrypt dropdown at the top of the screen, and select the Encrypt with Password option. In the resulting pop-up window (“Are you sure you want to change the security on this document?”), select Yes.

c.

Select the checkbox next to the Require a password to open the document option towards the top of the window – enter a password in the Document Open Password text field, and click OK. In the resulting confirmation window, re-enter the password and click OK.

d.

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

4) Save the file using the following file-naming convention: ApplicantLastNameRequestDate (MM/DD/YYYY) (e.g., Smith12042008.pdf) 5) Email the file as an attachment to with a Subject line of "DHS Directorate – 11000.25 Request – Date” (e.g., OPO – 11000.25 Request – 11/20/2008).

6) In a second email to the Office of Security using the same Subject line, send the password used to protect the information contained in the attachments.

Note: Please create or scan only one DHS form 11000.25 within a file attachment. If sending multiple attachments in a single email message, please use the same password for all attachments contained within the message.

DHS Form 11000-25 (7/17)