CDC VISITOR REQUEST FORM - Fort Collins Campus - Form 0.1586 (E) Ver20240515.pdf

FOR OFFICIAL USE ONLY

CDC Visitor Request Form

0.1586 (E) Ver:3 2024

Edition Date:15 May 2024

WARNING: This document is FOR OFFICIAL USE ONLY (FOUO). It contains information that may be exempt from public release under the Freedom of Information Act (5 U.S.C. 552).

It is to be controlled, stored, handled, transmitted, distributed, and disposed of in accordance with CDC policy relating to FOUO information and is not to be released to the public or personnel who do not have a valid “need-to-know” without prior approval of the authorized CDC official. The Centers for Disease Control and Prevention is authorized to collect the information requested on this form under the authority of 5 U.S.C. 7511, 18 U.S.C. 701, U.S.C. 490, and Executive Order 9397. The information is required for identity verification and to process your request for access into secure rooms. Data may be shared with authorized CDC and/or CDC contractor personnel. Furnishing the requested data is voluntary;

however, without your complete information, CDC staff may be unable to process your request.

Visitor Request Form Instructions & Disclosures on reverse side

Visit Information

1. Visitor’s Full Name (First, Middle, Last)

2. Date of Birth:

(MM/DD/YYYY)

3. Identification Type:

4. Identification Number:

5. Expiration Date:

6. U.S. Citizen:

(If No - See Notes Pg.) ☐ YES ☐ NO

7. Place of Birth:

(City & State or City & Country)

8. Dates of Visit: 9. Time of Visit: Start:

End:

10. Campus Name, Building & Room:

11. Purpose of Visit:

12. Access to Laboratories or Restricted Areas:

☐ YES ☐ NO 13. Access to Select Agent (SA) Laboratories:

☐ YES ☐ NO

14. Branch Chief or Designee Approval:

15. RO Approval:

16. CDC Host Name: 17. CDC Host Phone:

18. CDC Host Signature:

19. Special Note:

20. Designated Escort or Admin:

21. Escort / Admin Phone:

22. Host Responsibilities

If you are hosting a visitor, you are responsible for the actions of the person you have invited to visit CDC facilities. The host must:

• Be sure the visitor is aware of and agrees to follow all Visitor policies and procedures.

• Be sure the visitor is aware of and agrees to follow all Security policies and procedures.

• Be sure that the visitor is approved for access to all visited areas.

• Be sure the visitor does not have unauthorized or unintentional access to sensitive materials.

• Escort the visitor or designate an approved person to serve as the visitor’s escort.

• Tell the visitor about safety, security, and emergency response procedures for the visited areas.

• Be sure the visitor returns their badge to the nearest guard station at the end of the visit.

• You MUST be a US Citizen & an FTE to serve as a Host at all CDC Facilities

For Security Office Use

Date entered Visitor Database & notified requestor of approval:

Security Specialist Name:

Security Specialist Signature:

(Select the Campus and List All Building(s) and All Room numbers the Visitor Will Needs Access to)

(Describe the Purpose of the Visit or Write “New Employee”)

Must be an FTE

* Reminder:

1. Maximum number of Visitors per

Escort = 5

2. Maximum number of days per year per visitor = 45

3. Maximum number of consecutive days on one visit = 30

4. Never leave a visitor unattended!

(If Yes BC Must Sign Below) (If Yes RO Must Sign Below) yss5 Highlight

WARNING: This document is FOR OFFICIAL USE ONLY (FOUO). It contains information that may be exempt from public release under the Freedom of Information Act (5 U.S.C. 552).

It is to be controlled, stored, handled, transmitted, distributed, and disposed of in accordance with CDC policy relating to FOUO information and is not to be released to the public or personnel who do not have a valid “need-to-know” without prior approval of the authorized CDC official. The Centers for Disease Control and Prevention is authorized to collect the information requested on this form under the authority of 5 U.S.C. 7511, 18 U.S.C. 701, U.S.C. 490, and Executive Order 9397. The information is required for identity verification and to process your request for access into secure rooms. Data may be shared with authorized CDC and/or CDC contractor personnel. Furnishing the requested data is voluntary;

however, without your complete information, CDC staff may be unable to process your request.

CDC – Visitor Request Form – Instructions Purpose: Use this Form when requesting ALL “Visits” and to notify Security. Type all boxes or Print Clearly – this form is fillable, forms that cannot be read will be rejected.

Protection of Personally Identifiable Information (PII) When completed, this form should not be transmitted via e-mail without encrypting the e-mail or password-protecting the attachment. If password-protected, the password must be provided separately (e.g., by phone, separate email, in person, or fax) to the intended receiver. The preferred method of protection is to send the information by encrypting the e-mail or via fax. Fort Collins SOC Security Office fax # is: 970-225-4277

Authority to Request this Information The United States Government is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, United States Code; and parts 5, 731, and 736 of Title 5, Code of Federal Regulations. Your Social Security Number may also be needed to keep records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701, also asks Federal agencies to use this number to help identify individuals in agency records.

Disclosure of Information The information you give us is for the purpose of determining your suitability for Federal employment and/or for security purposes and to provide you access to US Government Facilities; we will protect your information from unauthorized disclosure. The collection, maintenance, and disclosure of this information is governed by the Privacy Act. This agency has published notices in the Federal Register describing the systems of records in which your records will be maintained. You may obtain copies of the relevant notices from the person who gave you this form. The information on this form, and the information we collect during any investigation may be disclosed without your consent as permitted by the Privacy Act (5 USC 552a(b)).

Instructions

1. Enter the First, Middle, and Last Name of the Visitor.

2. Enter the Complete date of Birth in the following Format MM/DD/YYYY.

3. Select the Identification Type from the drop down.

4. Enter the Identification Type number (i.e. Drivers License Number if selecting Drivers License as the ID Type)

NOTE: Enter State abbreviations with all State ID #s or Drivers Lic. #s, example: TX123456789 for a Texas Drivers Lic.

5. Enter the Identification Type expiration date.

NOTE: Cannot be expired on date of entry.

6. Enter Yes or No for US Citizenship, if No please see your Branch NCAMS Rep or use the following link to enter a Non-US Citizen Visit

Request Non-U.S. Citizens Access Management System (NCAMS).

NOTE A: To qualify as a US Citizen you must have one of the following; a Birth Certificate from the U.S. or a U.S. territory/possession, a Naturalization Certificate, a Citizenship Certificate, a State Department Form 240, or a U.S. Passport.

NOTE B: To use the NCAMS System you must be approved to use NCAMS system.

7. Enter your place of birth including full city name and state, please spell out your state, or enter full city and country if born outside the USA.

8. Enter the expected Start and End dates of the visit in the following format MM/DD/YYYY or enter “New Employee” and the start date.

9. Enter the time of the visit if known or enter 7am to 6pm if visiting multiple days or enter “New Employee”.

10. Enter the building number (s) and all Room Numbers including labs that the visitor needs access too, NON-SA Only.

11. Enter/Describe in detail the reason and purpose of the visit or enter “New Employee”.

12. Check Yes or No. (This for any Labs and Restricted Areas - i.e. any Labs or any dangerous areas such as a welding shop, chemical storage, all mechanical areas, roofs, or any areas that are dangerous or present a risk to non CDC-personnel)

13. Check Yes or No. (This for any Select Agent Labs ONLY)

14. Enter the Branch Chief or Designee signature here.

15. Enter the Select Agent Responsible Official signature here.

NOTE: Only if SA Lab Access is requested. THIS IS NOT AN APPROVAL TO ACCESS Select Agents.

16. Enter CDC Host Full Name or approved requester. (You may use an approved requester Only if lab/sensitive area access is not required).

17. Enter CDC Host phone number.

18. Enter CDC Host Signature or approved requester. (You may use an approved requester Only if lab/sensitive area access is not required).

19. Enter Special notes or Special VIP Status. (VIP Status is approved by DVBD Director and/or SOC only)

20. Enter designated Escort &/or Admin person responsible.

21. Enter designated Escort &/or Admin phone number (s).

22. Both Host and Escort Must Read and Comply with the listed responsibilities.

23. **Submit this form No Later Than (NLT) three (3) working days prior to any visit**

CDC Visitor Request Form

0.1586 (E) Ver:3 2024

Edition Date:15 May 2024

FOR OFFICIAL USE ONLY

* Send all Visitor Requests to your campus Physical Security POC (Primary) or the SOC, they will verify/approve your visitor request and forward it to the campus Guard Force.

* For additional information on requesting visitors, including information on requesting Non-U.S. citizen visitors, and rules for visitors and hosts please see CDC Visitors.

* For Special Circumstances or Mass Visit Requests please contact the SOC:

Atlanta SOC Fort Collins SOC

- cdcsecurit@cdc.gov or 404-639-2888

- ncidvbisecurity@cdc.gov or 970-494-6500

* Print Form Front to Back: When printing, if needed, please print front to back in accordance with HHS Policy to go green and reduce our waste.

* Proponent for this form is the Security Services Office, Fort Collins CO, Centers for Disease Control.

http://visitors.cdc.gov/ mailto:FC_VisitorRequests@cdc.gov https://intranet.cdc.gov/ossam/security-access/visitors/index.html yss5 Cross-Out mailto:cdcsecurit@cdc.gov mailto:ncidvbisecurity@cdc.gov