Attachment 0005 - DD Form 254.pdf

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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PREVIOUS EDITION IS OBSOLETE.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)

Classified (SECRET) material will the be accessed at US Army PM SMD within Classified areas. Access to Secret Internet Protocol Router Network (SIPRNET) is one of the reasons for requiring SECRET access. DOD requirement documents are sent to PM SMD for review as Tasks via SIPRNET and the Contractor will review these documents on SIPRNET and provide support for Government responses. Ref 10j: For Official Use Only (FOUO) Information generated and/or provided under this contract shall be safeguarded and marked as specified in DoD 5200.01 Vols 1-4.

Ref 10k: Secret Internet Protocol Network (SIPRNET) access required. The contractor shall not access, download or further disseminate any special access data (i.e. intelligence, NATO, COMSEC, etc.) outside the execution of the defined contract requirements and without the guidance and written permission of the COR. In the event that any special access is required, the COR must modify the requirements for the DD Form 254. Ref 11a: Contractor performance is at PM SMD. Government agency or activity will provide security classification guidance for performance of this contract. Submit visit request to the COR and/or Security Management Office for need-to-know verification.

Ref 11e: Contract is for services. Cleared individual is required to access SIPRNET and review military medical capability documentation and offer recommended responses. A majority of documentation on SIPRNET for review is UNCLASSIFIED. REASON FOR CLASSIFICATION: For SIPRNET access as detailed above. TRAINING REQUIREMENTS: AT Level 1, I-WATCH, OPSEC, Information Assurance, Handling/Access to Classified Information, TARP, and SIPRNET training for access.

“The undersigned has reviewed this Security Specification, understands the provisions and will ensure that it is complied with within the limits of his/her responsibility,and that any violations are brought to the attention of the COR (Mr. Joseph Martin) and supporting Security Manager." See DD254 Continuation attachment.

Natick, MA 01760