ATT 12 - Contractor Fitness Security Screening Request.pdf

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR FITNESS/SECURITY SCREENING REQUEST FORM

DHS Form 11000-25 (04/2023) Page 1 of 4UNCLASSIFIED//FOR OFFICIAL USE ONLY

OMB No. 1601-0029 Expiration: 4/30/2027

PRIVACY ACT STATEMENT

Authority: Executive Order (EO) 9397; EO 13467; EO 13764; 5 Code of Federal Regulations Parts 731 and 732; Federal Acquisition Regulation (FAR) 52.204-2 and 52.204-9; and Homeland Security Presidential Directive 12.

Principle Purpose: To make trust determinations associated with an individual's initial and ongoing fitness for contract employment, eligibility to hold a sensitive position or for access to classified, or eligibility for access to federally controlled facilities or information systems.

Routine Use(s): The information collected may be disclosed as generally permitted the Privacy Act. This includes using the information as necessary and authorized by the routine uses published in “DHS/ALL – 023 Personnel Security Management System of Records”.

Disclosure: Providing this information is voluntary; however, failure to provide this information may delay or prevent an individual's fitness determination and eligibility.

PUBLIC BURDEN STATEMENT

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering any required information, completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: PERSECPOLICY@HQ.DHS.GOV.

Please refer to the appended instructions when completing this form. Incomplete forms will be returned.

Section I: Requesting Official/Organization

1. Date of Submission 1

3. Type of Request Select

2. DHS Organization 1 Select

4. Exit Request Reason 1 Select

5a. CO:

Name:1 Last First

Phone DHS Email 1

5b. COR/Federal POC:

Name:1 Last First

Phone DHS Email 1

6. Prime Contractor 7. Prime Contract No.

8. Task Order No. 9. PIV Required Select

10. DHS Organization Structure Code

Section II: Applicant Information

11. Applicant Name: 1

Last First Middle

12. Position Title 1

13. SSN 1

15. Place of Birth

City State

Country Select

16. Date of Birth 17. U.S. Citizen

18. Phone 19. Email

14. Gender

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR FITNESS/SECURITY SCREENING REQUEST FORM

DHS Form 11000-25 (04/2023) Page 2 of 4UNCLASSIFIED//FOR OFFICIAL USE ONLY

OMB No. 1601-0029 Expiration: 4/30/2027

Section III: Position Designation

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.

20. Position Risk Level

Section IV: Position Security Clearance Requirement

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.

21. Security Clearance Level 22. DD254 on File

1 Indicates fields are required for completing the Exit Request

DHS Form 11000-25 (04/2023) Page 3 of 4

Instructions - Completing DHS Form 11000-25, Contractor Fitness/Security Screening Request

General

The DHS form11000-25, 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 identified in the contract. 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. The position designation is critical to the contractor fitness process in that it determines the Investigative requirements and eligibility associated with the position. DHS recognizes and reciprocates contractor investigations and eligibilities to the fullest extent possible. The contractor must meet/exceed the background investigation and eligibility for the contract requirements for reciprocity.

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.

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

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

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).

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

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 (1N) – 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.

DHS Form 11000-25 (04/2023) Page 4 of 4

Instructions - Completing DHS Form 11000-25, Contractor Fitness/Security Screening Request

• 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.

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 DHSHQ.INDUSTRIALSECURITY2@HQ.DHS.GOV.

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.