72592 - (CUI) Sol DD Form 254 - F3QCCL2112A001 Teradyn.pdf

CLASSIFICATION (When filled in): CUI

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AEM LiveCycle Designer DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE. Page 1 of 4

AEM LiveCycle Designer

DD FORM 254, APR 2018

DEPARTMENT OF DEFENSE

CONTRACT SECURITY CLASSIFICATION SPECIFICATION

(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.)

OMB No. 0704-0567 OMB approval expires:

October 31, 2020

The public reporting burden for this collection of information, 0704-0567, is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

RETURN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.

1. CLEARANCE AND SAFEGUARDING

a. LEVEL OF FACILITY SECURITY CLEARANCE (FCL) REQUIRED

(See Instructions)

Secret

b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/

MATERIAL REQUIRED AT CONTRACTOR FACILITY

None (See instructions)

2. THIS SPECIFICATION IS FOR: (X and complete as applicable.)

a. PRIME CONTRACT NUMBER (See instructions.)

b. SUBCONTRACT NUMBER

c. SOLICITATION OR OTHER NUMBER

F3QCCL2112A001

DUE DATE (YYYYMMDD)

3. THIS SPECIFICATION IS: (X and complete as applicable.)

a. ORIGINAL (Complete date in all cases.)

DATE (YYYYMMDD)

20220210

b. REVISED (Supersedes all previous specifications.)

REVISION NO. DATE (YYYYMMDD)

c. FINAL (Complete Item 5 in all cases.) DATE (YYYYMMDD)

4. IS THIS A FOLLOW-ON CONTRACT? No Yes If yes, complete the following:

Classified material received or generated under (Preceding Contract Number) is transferred to this follow-on contract.

5. IS THIS A FINAL DD FORM 254? No Yes If yes, complete the following:

In response to the contractor's request dated , retention of the classified material is authorized for the period of:

6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)

a. NAME, ADDRESS, AND ZIP CODE Teradyne, Inc.

Teradyne Assembly Test Division 600 Riverpark Drive North Reading, MA 01864

b. CAGE CODE

23350

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional) Defense Counterintelligence & Security Agency Andover Field Office (IOFNA) 1 Tech Drive, Suite 330 Andover, MA 01810

7. SUBCONTRACTOR(S) (Click button if you choose to add or list the subcontractors -- but will still require a separate DD Form 254 issued by a prime contractor to each subcontractor) Add Row Remove last Row Delete All Rows

a. NAME, ADDRESS, AND ZIP CODE

N/A

b. CAGE CODE

N/A

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

N/A

8. ACTUAL PERFORMANCE (Click button to add more locations.) Add Row Remove last Row Delete All Rows

a. LOCATION(S) (For actual performance, see instructions.)

402d Electronic Maintenance Support Group Bldg 640 640 Page Rd Robins AFB, GA 31098

b. CAGE CODE (If applicable, see Instructions.)

N/A

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

78 ABW/IPD

985 Macon Street Robins AFB, GA 31098

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

The purpose of this requirement is for the calibration, preventive maintenance, unscheduled maintenance, and replacement parts for Teradyne Spectrum, TS-128, and multiple Versatile Diagnostic Automatic Test Station (VDATS) located on 12 Automatic Test Equipment (ATE) systems.

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DD FORM 254, APR 2018

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)

a. COMMUNICATIONS SECURITY (COMSEC) INFORMATION f. SPECIAL ACCESS PROGRAM (SAP) INFORMATION

b. RESTRICTED DATA g. NORTH ATLANTIC TREATY ORGANIZATION

(NATO) INFORMATION

c. CRITICAL NUCLEAR WEAPON DESIGN INFORMATION (CNWDI) (If CNWDI applies, RESTRICTED DATA must also be marked.) h. FOREIGN GOVERMENT INFORMATION

d. FORMERLY RESTRICTED DATA i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

e. NATIONAL INTELLIGENCE INFORMATION:

(1) Sensitive Compartmented Information (SCI)

(2) Non-SCI

j. CONTROLLED UNCLASSIFIED INFORMATION (CUI) (See instructions.)

k. OTHER (Specify) (See instructions.)

11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 13 or 14 as set forth in the instructions.)

a. HAVE ACCESS TO CLASSIFIED INFORMATION ONLY AT

ANOTHER CONTRACTOR'S FACILITY OR A GOVERNMENT

ACTIVITY

(Applicable only if there is no access or storage required at contractor facility.

See instructions.)

b. RECEIVE AND STORE CLASSIFIED DOCUMENTS ONLY

c. RECEIVE, STORE, AND GENERATE CLASSIFIED

INFORMATION OR MATERIAL

d. FABRICATE, MODIFY, OR STORE CLASSIFIED HARDWARE

e. PERFORM SERVICES ONLY

f. HAVE ACCESS TO U.S. CLASSIFIED INFORMATION OUTSIDE

THE U.S.,PUERTO RICO, U.S. POSSESSIONS AND TRUST

TERRITORIES

g. BE AUTHORIZED TO USE THE SERVICES OF DEFENSE

TECHNICAL INFORMATION CENTER (DTIC) OR OTHER

SECONDARY DISTRIBUTION CENTER

h. REQUIRE A COMSEC ACCOUNT

i. HAVE A TEMPEST REQUIREMENT

j. HAVE OPERATIONS SECURITY (OPSEC) REQUIREMENTS

k. BE AUTHORIZED TO USE DEFENSE COURIER SERVICE

l. RECEIVE, STORE, OR GENERATE CONTROLLED UNCLASSIFIED

INFORMATION (CUI).

(DoD Components: refer to DoDM 5200.01, Volume 4 only for specific CUI protection requirements. Non-DoD Components: see instructions.)

m. OTHER (Specify) (See instructions.)

12. PUBLIC RELEASE

Any information (classified or unclassified) pertaining to this contract shall not be released for public dissemination except as provided by the National Industrial Security Program Operating Manual (NISPOM) or unless it has been approved for public release by appropriate U.S. Government authority.

Proposed public releases shall be submitted for review and approval prior to release to the appropriate government approval authority identified here with at least office and phone contact information and if available, an e-mail address. (See instructions)

DIRECT THROUGH (Specify below)

See Block 13

Public Release Authority:

See Block 13

13. SECURITY GUIDANCE Add Signature Remove last Signature Delete All Signatures

The security classification guidance for classified information needed for this effort is identified below. If any difficulty is encountered in applying this guidance or if any other contributing factor indicates a need for changes in this guidance, the contractor is authorized and encouraged to provide recommended changes; to challenge the guidance or the classification assigned to any information or material furnished or generated under this contract;

and to submit any questions for interpretation of this guidance to the official identified below. Pending final decision, the information involved shall be handled and protected at the highest level of classification assigned or recommended.

(Fill in as appropriate for the classified effort. Attach, or forward under separate correspondence, any documents/guides/extracts referenced herein. The field will expand as text is added. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. Also allows for up to 6 internal reviewers to digitally sign. See instructions for additional guidance or use of the fillable PDF.)

Ref Item 8a and 11a: Contract performance will occur intermittently on Robins AFB within Bldgs 640/645 (740 & 640 Page Rd, Robins AFB, GA 31098). The Contractor shall forward visit requests through the Defense Information System for Security (DISS) to the 402d EMXG, Visitor Control Center (VCC) located at 420 Richard Ray Blvd, Suite 100, Robins AFB, GA 31098.

Ref Items10j and 11l: The contractor shall comply with DoDI 5200.48, Controlled Unclassified Information, DoDM 5200.01V3_AFMAN 16-1404V3, Information Security Program Protection of Classified Information and DoDM 5400.7-Air Force Manual 33 302, DoD Freedom of Information Act (FOIA) Program. The contractor shall monitor CUI aggregation and compilation based on the potential to generate classified information pursuant to security classification guidance addressing the accumulation of unclassified data or information.

Ref Item 11e: Contract is for equipment maintenance services. Actual knowledge of, generation, or production of classified information is not required for performance of the contract. Cleared personnel are required to perform this service because access to classified information cannot be precluded by escorting personnel.

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DD FORM 254, APR 2018

Ref Item 11j: The Contractor will be provided critical information under separate cover, if applicable.

Ref Item 12: Contractor is to submit requests through the contracting officer for OPSEC program manager review and public release authorization. The contracting officer will provide contractor with written approval/disapproval. Information requiring AF or DoD-level review will be reviewed by the unit’s OPSEC program manager or coordinator who will in-turn forward to the entry-level public affairs office through the AFIMSC Public Affairs Office to the Secretary of the Air Force, Office of Public Affairs, Security and Review Division (SAF/PAX), 1690 Air Force Pentagon, Washington DC 20330-1690.

List of Attachments (All Files Must be Attached Prior to Signing, i.e., for any digital signature on the form)

Add Attachment View Selected Attachment Remove Selected Attachment

WR-ALC/OBCA

478-926-2828 DSN 468

NAME & TITLE OF REVIEWING OFFICIAL

Crystal Wainwright Acquisition Support Specialist

SIGNATURE

402 EMXG/MXDSMB

478-926-1948 DSN 468

NAME & TITLE OF REVIEWING OFFICIAL

Joe Huddleston Security Specialist

WR-ALC/OMD

478-926-6095 DSN 468

NAME & TITLE OF REVIEWING OFFICIAL

Clinton Breeze OPSEC Signature Manager

78 ABW/IP

478-222-1977 DSN 472

NAME & TITLE OF REVIEWING OFFICIAL

Melvese Harris USAF Servicing Security Activity

SIGNATURE

14. ADDITIONAL SECURITY REQUIREMENTS

Requirements, in addition to NISPOM requirements for classified information, are established for this contract.

No Yes If Yes, identify the pertinent contractual clauses in the contract document itself, or provide an appropriate statement which identifies the additional requirements. Provide a copy of the requirements to the CSO. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted.

(See instructions for additional guidance or use of the fillable PDF.)

15. INSPECTIONS

Elements of this contract are outside the inspection responsibility of the CSO.

No Yes If Yes, explain and identify specific areas and government activity responsible for inspections. The field will expand as text is added or you can also use item

13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted.

(See instructions for additional guidance or use of the fillable PDF.)

16. GOVERNMENT CONTRACTING ACTIVITY (GCA) AND POINT OF CONTACT (POC)

a. GCA NAME

AFMC AFSC/PZIM

b. ACTIVITY ADDRESS CODE (AAC) OF THE CONTRACTING OFFICE (See Instructions)

FA8571

c. ADDRESS (Include ZIP Code)

Robins Air Force Base 375 Perry St, Building 255, Suite A Robins AFB, GA 31098

d. POC NAME

Jesse Schwarztrauber

e. POC TELEPHONE (Include Area Code)

+1 (575) 265-9515

f. EMAIL ADDRESS (See Instructions) jesse.schwarztrauber.1@us.af.mil

17. CERTIFICATION AND SIGNATURES

Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. Upon digitally signing Item 17h, no changes can be made as the form will be locked.

a. TYPED NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) (See Instructions)

Jesse Schwarztrauber

b. TITLE

PCO

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DD FORM 254, APR 2018

c. ADDRESS (Include ZIP Code) Robins Air Force Base 375 Perry St, Building 255, Suite A Robins AFB, GA 31098

d. AAC OF THE CONTRACTING OFFICE (See Instructions)

e. CAGE CODE OF THE PRIME CONTRACTOR (See Instructions.)

f. TELEPHONE (Include Area Code)

+1 (575) 265-9515

g. EMAIL ADDRESS (See Instructions) jesse.schwarztrauber.1@us.af.mil

h. SIGNATURE

i. DATE SIGNED (See Instructions)

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

a. CONTRACTOR

b. SUBCONTRACTOR

c. COGNIZANT SECURITY OFFICE FOR PRIME AND

SUBCONTRACTOR

d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY

ADMINISTRATION

e. ADMINISTRATIVE CONTRACTING OFFICER

f. OTHER AS NECESSARY (If more room is needed, continue in Item 13 or on additional page if necessary.)

402 EMXG Security Office

78 ABW/IPD

WR-ALC/OMD Security Office

DRAFT

SAMPLE

PREVIOUS EDITION IS OBSOLETE.

Page of AEM LiveCycle Designer

DD FORM 254, APR 2018

NEEDS DD67

DEPARTMENT OF DEFENSE

CONTRACT SECURITY CLASSIFICATION SPECIFICATION

(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.)

OMB No. 0704-0567 OMB approval expires:

October 31, 2020 The public reporting burden for this collection of information, 0704-0567, is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

RETURN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.

1. CLEARANCE AND SAFEGUARDING

2. THIS SPECIFICATION IS FOR: (X and complete as applicable.)

3. THIS SPECIFICATION IS: (X and complete as applicable.)

a. ORIGINAL (Complete date in all cases.)

b. REVISED (Supersedes all previous specifications.)

4. IS THIS A FOLLOW-ON CONTRACT?

If yes, complete the following:

Classified material received or generated under

5. IS THIS A FINAL DD FORM 254?

If yes, complete the following:

6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)

7. SUBCONTRACTOR(S) (Click button if you choose to add or list the subcontractors -- but will still require a separate DD Form 254 issued by a prime contractor to each subcontractor)

8. ACTUAL PERFORMANCE (Click button to add more locations.)

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)

e. NATIONAL INTELLIGENCE INFORMATION:

11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 13 or 14 as set forth in the instructions.)

12. PUBLIC RELEASE

Any information (classified or unclassified) pertaining to this contract shall not be released for public dissemination except as provided by the National Industrial Security Program Operating Manual (NISPOM) or unless it has been approved for public release by appropriate U.S. Government authority. Proposed public releases shall be submitted for review and approval prior to release to the appropriate government approval authority identified here with at least office and phone contact information and if available, an e-mail address. (See instructions)

13. SECURITY GUIDANCE

The security classification guidance for classified information needed for this effort is identified below. If any difficulty is encountered in applying this guidance or if any other contributing factor indicates a need for changes in this guidance, the contractor is authorized and encouraged to provide recommended changes; to challenge the guidance or the classification assigned to any information or material furnished or generated under this contract; and to submit any questions for interpretation of this guidance to the official identified below. Pending final decision, the information involved shall be handled and protected at the highest level of classification assigned or recommended.

(Fill in as appropriate for the classified effort. Attach, or forward under separate correspondence, any documents/guides/extracts referenced herein. The field will expand as text is added. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. Also allows for up to 6 internal reviewers to digitally sign. See instructions for additional guidance or use of the fillable PDF.)

14. ADDITIONAL SECURITY REQUIREMENTS

Requirements, in addition to NISPOM requirements for classified information, are established for this contract.

If Yes, identify the pertinent contractual clauses in the contract document itself, or provide an appropriate statement which identifies the additional requirements. Provide a copy of the requirements to the CSO. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. (See instructions for additional guidance or use of the fillable PDF.)

15. INSPECTIONS

Elements of this contract are outside the inspection responsibility of the CSO.

If Yes, explain and identify specific areas and government activity responsible for inspections. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. (See instructions for additional guidance or use of the fillable PDF.)

16. GOVERNMENT CONTRACTING ACTIVITY (GCA) AND POINT OF CONTACT (POC)

17. CERTIFICATION AND SIGNATURES

Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. Upon digitally signing Item 17h, no changes can be made as the form will be locked.

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

9.0.0.2.20120627.2.874785 DD 254, DoD Contract Security Classification Specification List of Attachments (All Files Must be Attached Prior to Signing, i.e., for any digital signature on the form)

Teradyne Assembly Test Division 600 Riverpark Drive North Reading, MA 01864 Name:

N/A

Andover Field Office (IOFNA) 1 Tech Drive, Suite 330 Andover, MA 01810

CSO:

N/A

CSO:

78 ABW/IPD

985 Macon Street Robins AFB, GA 31098

402d Electronic Maintenance Support Group Bldg 640 640 Page Rd Robins AFB, GA 31098 Block9:

The purpose of this requirement is for the calibration, preventive maintenance, unscheduled maintenance, and replacement parts for Teradyne Spectrum, TS-128, and multiple Versatile Diagnostic Automatic Test Station (VDATS) located on 12 Automatic Test Equipment (ATE) systems.

78 ABW/IPD

WR-ALC/OMD Security Office

Ref Items10j and 11l: The contractor shall comply with DoDI 5200.48, Controlled Unclassified Information, DoDM 5200.01V3_AFMAN 16-1404V3, Information Security Program Protection of Classified Information and DoDM 5400.7-Air Force Manual 33 302, DoD Freedom of Information Act (FOIA) Program. The contractor shall monitor CUI aggregation and compilation based on the potential to generate classified information pursuant to security classification guidance addressing the accumulation of unclassified data or information.

Ref Item 11e: Contract is for equipment maintenance services. Actual knowledge of, generation, or production of classified information is not required for performance of the contract. Cleared personnel are required to perform this service because access to classified information cannot be precluded by escorting personnel.

Ref Item 11j: The Contractor will be provided critical information under separate cover, if applicable.

Ref Item 12: Contractor is to submit requests through the contracting officer for OPSEC program manager review and public release authorization. The contracting officer will provide contractor with written approval/disapproval. Information requiring AF or DoD-level review will be reviewed by the unit’s OPSEC program manager or coordinator who will in-turn forward to the entry-level public affairs office through the AFIMSC Public Affairs Office to the Secretary of the Air Force, Office of Public Affairs, Security and Review Division (SAF/PAX), 1690 Air Force Pentagon, Washington DC 20330-1690.

text:

WR-ALC/OBCA

478-926-2828 DSN 468

text:

402 EMXG/MXDSMB

478-926-1948 DSN 468

text:

WR-ALC/OMD

478-926-6095 DSN 468

text:

78 ABW/IP

478-222-1977 DSN 472

Acquisition Support Specialist rep: Joe Huddleston Security Specialist rep: Clinton Breeze OPSEC Signature Manager rep: Melvese Harris USAF Servicing Security Activity

Robins Air Force Base 375 Perry St, Building 255, Suite A Robins AFB, GA 31098 Address: Robins Air Force Base 375 Perry St, Building 255, Suite A Robins AFB, GA 31098