Attach01 DD Form 254.pdf

CLASSIFICATION (When filled in): Unclassified NRL SER: 016-21

DEPARTMENT OF DEFENSE 0MB No. 0704-0567

CONTRACT SECURITY CLASSIFICATION SPECIFICATION 0MB approval expires:

(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.) 20220531

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 0MB control number.

RETURN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.

1. CLEARANCE AND SAFEGUARDING

a. LEVEL OF FACILITY SECURITY CLEARANCE (FCL) REQUIRED b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/ (See Instructions) MATERIAL REQUIRED AT CONTRACTOR FACILITY

Secret None (Sec instructions)

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

• a. PRIME CONTRACT NUMBER (See instructions.)

DA TE (YYYYMMDO)

a. ORIGINAL (Complete date in all cases.)

20210303

• b. SUBCONTRACT NUMBER b. REVISED (Supersedes all previous specifications.)

• REVISION NO. DA TE (YYYYMMDD)

c. SOLICITATION OR OTHER NUMBER DUE DATE (YYYYMMDD)

~ N00173-21-R-ZL05 • c. FINAL (Complete Item 5 in all cases.) DATE (YYYYMMDD)

4. IS THIS A FOLLOW-ON CONTRACT? ~ No D 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 D 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 b. CAGE CODE c. COGNIZANT SECURITY OFFICE($) (CSO)

FOR RFP PURPOSES ONLY; NOT VALID FOR (Name, Address, ZIP Code, Telephone required; Email Address optional)

DEFENSE COUNTERINTELLIGENCE AND

ACTUAL CONTRACT A WARD

SECURITY AGENCY

NIA

7. SUBCONTRACTOR($) (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)

a. NAME, ADDRESS, AND ZIP CODE b. CAGE CODE c. COGNIZANT SECURITY OFFICE($) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

NIA NIA

NIA

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

a. LOCATION(S) (For actual performance, see instructions.) b. CAGE CODE c. COGNIZANT SECURITY OFFICE($) (CSO) (If applicable, (Name, Address, ZIP Code, Telephone required; Email Address optional)

SEE BLOCK 13

see Instructions.)

NIA

NIA

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

R&D SUPPORT SERVICES CONTRACT FOR CHEMICAL, BIOLOGICAL AND PHYSICAL SENSORS, AND MATERIALS

SYNTHESIS AND CHARACTERIZATION.

DD FORM 254, MAY 2019 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): Unclassified

NRL SER: 016-21

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

0 a. COMMUNICATIONS SECURITY (COMSEC) INFORMATION

0 b. RESTRICTED DATA

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

0 d. FORMERLY RESTRICTED DATA

e. NATIONAL INTELLIGENCE INFORMATION:

D (1) Sensitive Compartmented Information (SCI)

[gj (2) Non-SCI

0 f. SPECIAL ACCESS PROGRAM (SAP) INFORMATION

• g. NORTH ATLANTIC TREATY ORGANIZATION

(NATO) INFORMATION

0 h. FOREIGN GOVERMENT INFORMATION

• i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

[gj j, CONTROLLED UNCLASSIFIED INFORMATION (CUI) (See instructions.)

0 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

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

See instructions.)

0 b. RECEIVE AND STORE CLASSIFIED DOCUMENTS ONLY

• c. RECEIVE, STORE, AND GENERATE CLASSIFIED

INFORMATION OR MATERIAL

0 d. FABRICATE, MODIFY, OR STORE CLASSIFIED HARDWARE

0 e. PERFORM SERVICES ONLY

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

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

TERRITORIES

12. PUBLIC RELEASE

g. BE AUTHORIZED TO USE THE SERVICES OF DEFENSE

0 TECHNICAL INFORMATION CENTER (DTIC) OR OTHER

SECONDARY DISTRIBUTION CENTER

0 h. REQUIRE A COMSEC ACCOUNT

0 i. HAVE A TEMPEST REQUIREMENT

[gj j. HAVE OPERATIONS SECURITY (OPSEC) REQUIREMENTS

0 k. BE AUTHORIZED TO USE DEFENSE COURIER SERVICE

I. 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.)

0 m. OTHER (Specify) (See instructions.)

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)

D DIRECT [g] THROUGH (Specify below) I Public Release Authority:

13. SECURITY GUIDANCE

COMMANDING OFFICER, NAVAL RESEARCH

LABORATORY, WASHINGTON DC 20375-5320, CODE 6177

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 if 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.)

I . Contractor personnel must possess a favorably adjudicated DoD Tier 3 investigation and a final SECRET DoD granted personnel security clearance. The number of SECRET clearances requested from DCSA is anticipated not to exceed 30.

2. Foreign Nationals are not authorized to work on this contract.

3. Classified information or Controlled Unclassified Information (CUI), such as Proprietary, Privacy Act or FOUO, etc., information associated with this contract, must be handled/controlled IA W DoD 5200.48.

4. Contractor will NOT be required to receive, generate, or have custody of CLASSIFIED material at the contractor's facility .

5. All contractors (including subcontractors) identified in the Statement of Work shall supplement their current security practices by requiring any personnel involved in executing the contract to complete Government-sponsored and administered Operations Security (OPSEC) training, OPSE-1301 and any OPSEC guidance that may pertain to the project.

6. Visit requests and Need-to-know certifications are required for all personnel on this contract. Visit requests must include full name, SSN, contract number, clearance level , date of closed investigation and should state if IT access is required . Visit requests for OTHER U.S.

Government/DoD contractor facilities will be processed through the contractor FSO. Authorized work locations for this contract are listed below.

DD FORM 254, MAY 2019 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): Unclassified

7. The pnme contractor will forward a copy of all proposed subcontracts and task orders to the COR named in paragraph 9, related to this contract, regardless of classification, for review, approval and coordination with the official named in block 16d below. All subcontracts must be approved in writing, by the official named in block 16d below prior to the start of work .

8. Contractors issued a DoD interim secret security clearance may ONLY work on unclassified tasks as outlined in the SOW. Unclassified IA or IT positions are NOT authorized with a DoD issued interim secret clearance. Contract Facility Security Officers (FSOs), and/or NRL CORs, are required to report immediately to Code 1230 any derogatory information regarding a contractor holding an interim Secret clearance, either on- or off-site. FSOs and NRL CORs shall also notify Code 1230 when a contractor' s interim or final clearance has been declined or revoked.

9. The NRL COR for this contract is Shawn Mulvaney, NRL Code 6177, (202)404-2120. The Security point of contact for this contract is the official named in block 16d.

ACTUAL PERFORMANCE LOCATION:

NAVAL RESEARCH LABORATORY

4555 OVERLOOK A VENUE, SW

WASHINGTON, DC 20375

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

NAME & TITLE OF REVIEWING OFFICIAL SIGNATURE

14. ADDITIONAL SECURITY REQUIREMENTS

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

0 No cg] Yes ff 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 lex/ area, use delete key or backspace key, then click out of the text field for it lo shrink after the text has been deleted.

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

SEE BLOCK 13 , PARAGRAPH 5.

15. INSPECTIONS

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

l'v'I N D y 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

IC,!

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

(See ins/ructions for additional guidance or use of /he fillable PDF.)

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

a. GCA NAME

NAVAL RESEARCH LA BORA TORY

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

N00l73

17. CERTIFICATION AND SIGNATURES

c. ADDRESS (Include ZIP Code)

4555 OVERLOOK A VENUE, SW

WASHINGTON, DC 20375

d. POC NAME

JAMES D. MILLARD

e. POC TELEPHONE (Include Area Code)

+ I (202) 767-2576

f. EMAIL ADDRESS (See Instructions) dave.millard@nrl.navy.mil

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.

DD FORM 254, MAY 2019 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): Unclassified

a. TYPED NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) d. AAC OF THE CONTRACTING OFFICE h. SIGNATURE (See Instructions) (See Instructions) MILLAR Digitall y signed

MILLARD, JAMES N00l 73 by

e. CAGE CODE OF THE PRIME CONTRACTOR

D .JAME MI LLARD.JAM

b. TITLE ES. D.1•4262307

(See Instructions.) S.D.1042, BRANCH HEAD- INFORMATION SECURITY 623071

Date: 202 1.03.11 14:34:04 -05'00'

c. ADDRESS (Include ZIP Code) f. TELEPHONE (Include Area Code) i. DATE SIGNED

4555 OVERLOOK A VENUE, SW + 1 (202) 767-2576

(See Instructions)

WASHINGTON, DC 20375 g. EMAIL ADDRESS (See Instructions) 20210311 dave.millard@nrl.navy .mil

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

cg] a. CONTRACTOR cg] f. OTHER AS NECESSARY (ff more room is needed, continue in Item 13 oron additional page if necessary.)

0 b. SUBCONTRACTOR 1231 , 6102, 6177 cg] c. COGNIZANT SECURITY OFFICE FOR PRIME AND

SUBCONTRACTOR

0 d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY

ADMINISTRATION

cg] e. ADMINISTRATIVE CONTRACTING OFFICER

DD FORM 254, MAY 2019 PREVIOUS EDITION IS OBSOLETE. Page 4 of 4

NRL SER: 016-21 CLASSIFICATION (When filled in): Unclassified