Attachment 11 - AFRL Privacy Act for Covered Individuals Fillable (1).pdf
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- FA2394-26-R-B003
About this file
This is a Privacy Act Statement form issued by the Air Force Research Laboratory (AFRL) for use in federal research and development solicitations.
The form establishes the legal authority and purpose for collecting personal information from individuals and institutions submitting proposals for federal grants, cooperative agreements, contracts, and Other Transaction Agreements administered by the Department of the Air Force. The statement outlines that collected information may be used for processing, investigating, and maintaining records to ensure awards are made to responsible parties and entities. Information sharing is authorized to contractors, grantees, experts, consultants, and others performing work on federal contracts or grants, as well as to appropriate federal, state, local, and international law enforcement authorities when records indicate potential violations of law. The form specifies that while providing information is voluntary, 42 U.S. Code § 6605 imposes mandatory disclosure requirements for federal research and development awards, with enforcement mechanisms including civil or criminal remedies and rejection of non-compliant applications. The document includes signature blocks for a covered individual and the institution's authorized representative to acknowledge consent, along with fields for proposal title and institution name. This form serves as a template document required for AFRL research solicitations.
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Privacy Act Statement Air Force Research Laboratory
Authority: Government Paperwork Elimination Act (Pub. L. 105-277, 44 U.S.C. 3504); Executive Order 12372, Intergovernmental review of Federal Programs (47 FR 30959); 42 U.S. Code § 6605 – Disclosure of funding sources in applications for Federal research and development awards; Public Law 117-167, CHIPS and Science Act; Public Law 116-92, National Defense Authorization Act for Fiscal Year 2020;
Public Law 116-283, National Defense Authorization Act for Fiscal Year 2021; 5 U.S.C. 9101, Access to Criminal History for National Security and Other Purposes 5 CFR §1320.8, Agency collection of information Responsibility; 18 U.S.C. § 1001, False Statements, Concealment; E.O. 13478, Amendments to Executive Order 9397 Related to Federal Use of social Security Numbers; NSPM-33, National Security Presidential Memorandum 33 on National Security for United States Research and Development; DoD-D 5240.01, DoD Intelligence Activities; DoDI 5200.02, Department of Defense Personnel Security Program; DODI 5205.87 Mitigating Risks Related to Foreign Ownership, Control, or Influence for Covered DOD Contractors and Subcontractors; Air Force Research Laboratory Instruction 61-113, Science and Technology Protection for the Air Force Research Laboratory;
Purpose: The information collected may be used in processing, investigating, and maintaining records relevant to Federal Grants, Cooperative Agreements, Contracts, Other Transaction Agreements or other research related agreements awarded by the Department of the Air Force. Records in these systems will be used to ensure Department of the Air Force sponsored and/or awarded federal grants, cooperative agreements, contracts, Other Transaction Agreements and/or benefits are awarded to responsible parties, entities, and individuals.
Routine Uses: To contractors, grantees, experts, consultants, students, and others performing or working on a contract, grant, cooperative agreement, other transaction or other assignment for the Federal Government when necessary to accomplish an agency function.
To the appropriate Federal, State, local, territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law, whether criminal, civil, or regulatory in nature.
DoD Blanket Routine Use (http://dpcld.defense.gov/privacy)
Effect of not providing information: Providing information to the Department of the Air Force is voluntary. However, 42 U.S. Code § 6605, which imposes certain disclosure requirements in connection with Federal research and development awards, provides various enforcement mechanisms for non-compliance to include civil or criminal remedies. One such mechanism, which the Department of the Air Force intends to pursue here, is rejection of such applications.
Proposal Title: ____________________________
Acknowledgment of consent:
Covered individual (Signature): ______________________________ Date: ___________
Covered individual (Name print): ______________________________
Institution’s Authorized Representative (Signature): _______________________ Date: ___________
Institution’s Authorized Representative (Name print): ______________________________
Institution Name: _______________________________ http://dpcld.defense.gov/privacy
| Proposal Title: |
| Covered individual Name print: |
| Institutions Authorized Representative Name print: |
| Institution Name: |
| Date: |
| Date2: |
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