Attachment 4 - FEMA Access form FF-900-FY-21-100.pdf

FEMA Form FF-900-FY-21-100 (formerly 121-3-1-3A) (09/21)

OMB Control Number: 1660-0151 Expiration: September 30, 2024

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

FACILITY ACCESS REQUEST

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average .17 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This collection of information is required to obtain or retain benefits. You are not required to submit to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:

Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency (FEMA), 500 C Street SW, Washington, DC 20472, and Paperwork Reduction Project (1660-0151). NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why DHS is requesting the information on this form.

AUTHORITY: FEMA is authorized to collect the information requested on this form pursuant to 40 U.S.C § 13159 to protect the buildings, grounds, and property owned, occupied, or secured by the Federal Government, and the persons on the property.

PURPOSE: FEMA is requesting this information to collect and maintain records related to the Department's facility and perimeter access control, including access to DHS information technology and access to facilities, as well as visitor security and management. FEMA will use this information to support the Department's efforts related to protecting DHS facilities and operating the visitor management program.

ROUTINE USES: The information requested on this form may be shared externally as a “routine use” to FBI to assist the Department of Homeland Security in screening FEMA employees requesting access to high security areas and visitors that are not employed by the U.S.

Government. A complete list of the routine uses can be found in the system of records notice associated with this form, “Department of Homeland Security FEMA. DHS/ALL-024 Facility and Perimeter Access Control and Visitor Management System of Records, DHS/ALL-023 Personnel Security Management System of Records, DHS/ALL-025 Law Enforcement Authority in Support of the Protection of Property Owned, Occupied, or Secured by the Department of Homeland Security System of Records and DHS/ALL-026 Personal Identity Verification Management System of Records The Department's full list of system of records notices can be found on the Department's website at http:// www.dhs.gov/system-records-notices-sorns.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Providing this information to is voluntary. However, failure to provide this information may result in a denial of access to FEMA facilities.

INSTRUCTIONS FOR ACCESS TO FEMA FACILITIES

(FOR MOUNT WEATHER EOC (MWEOC) AREA A, SEE SPECIFIC INSTRUCTIONS BELOW)

1. To apply for access into FEMA controlled facilities, all applicants must TYPE or PRINT the applicable parts of this form. Fill out, sign and return to the point of contact. Part I of this form must be completed and signed by the person applying.

2. The point of contact must sign and forward completed form to the Facility Security Manager.

3. Applicants requesting access to be programmed onto an existing PIV Card must know their PIN Number.

Authorized personnel may have access to rooms/suite entry door within FEMA space only after coordination/endorsements from the servicing program office of the space in question and the Office of the Chief Security Officer (OCSO). If you have questions, you can call the OCSO at (202) 646-3012.

4. FEMA Employees or Contractors: Complete Part I.Visitors without an existing PIV Card: Complete Parts I and II. Guests requesting access with an existing PIV Card: Complete Parts I, II, and III.

INSTRUCTIONS FOR ACCESS TO MOUNT WEATHER EMERGENCY OPERATIONS CENTER (MWEOC) AREA A

1. Pursuant to CFR 44 Part 15, the FEMA Administrator or MWEOC Executive Director must approve all persons and vehicles entering

MWEOC.

2. Government Employees, Contractors or Vendors: Complete Part I - TYPE or PRINT Part I. Return the signed form to the approved MWEOC sponsor.

3. Approved MWEOC Sponsor: Complete Part II and forward the completed form to the MWEOC Access Control Office via fax at

540-542-2608 or by email at FEMA-MW-AreaA-Access@FEMA.DHS.GOV (Incomplete forms and forms not sent by an approved MWEOC sponsor will not be processed.)

4. Applicants requesting access to be programmed onto an existing PIV Card must know their PIN Number. Authorized personnel may have access to rooms/suite entry door within MWEOC only after coordination/endorsements from the approved MWEOC Sponsor of the space in question and the MWEOC Access Control Office. If you have questions, you can call the MWEOC Access Control office at (540) 542-2091.

NOTE: Signing this form signifies that I understand that this is a Release Of Information(ROI) . I understand that any false statement on any part of my application may be grounds for denying me access into Federal Emergency Management Agency controlled facilities, and/or grounds for prosecution under Title18 USC 1001.

***Please ensure to use a cover sheet and password protect or use other approved methods for the protection of the applicant's PII when submitting this form***

PART I - TO BE COMPLETED BY APPLICANT FOR ACCESS TO FEMA FACILITIES/MWEOC AREA A

***Signing this form is a release of Information (ROI)***

FULL NAME OF APPLICANT (Last, First, Middle, and Maiden if applicable) SPONSOR PROGRAM OFFICE

CURRENTLY HAVE A PIV, PIV-I, or CAC CARD? (Check one) YES NO

IF YES, WHAT ISSUING AGENCY?

DATE OF BIRTH (MM/DD/YYYY) SEX

MALE

FEMALE

TELEPHONE NUMBER

HOME

CELL

WORK

PLACE OF BIRTH (CITY, STATE, COUNTRY)

SOCIAL SECURITY NUMBER

DO YOU HOLD A U.S. CITIZENSHIP STATUS?

YES

NO

IF NO, PROVIDE ALIEN REGISTRATION #

ARE YOU A NATURALIZED CITIZEN?

YES

NO

IF YES, PROVIDE NATURALIZATION

DATE/ALIEN #

EMPLOYMENT STATUS

FEDERAL CONTRACTOR VENDOR OTHER

EMPLOYER AGENCY/COMPANY

SIGNATURE OF APPLICANT (see ROI/PRIVACY ACT STATEMENT) DATE

PART II - TO BE COMPLETED BY THE GOVERNMENT SPONSOR

***Signing this form is a release of Information (ROI)***

GOVERNMENT SPONSOR(Last, First, Middle) SPONSOR PROGRAM OFFICE

SITE(S) TO BE ACCESSED BY

APPLICANT (BUILDING)

FREQUENCY OF ACCESS REQUIRED (Check one)

Daily Weekly Monthly Other

LENGTH OF ACCESS REQUIREMENT

Start Date

End Date

FLOOR/ROOM/SUITE ENTRY DOOR TO

BE ACCESSED BY APPLICANT REASON FOR ACCESS (MEETING, CONTRACT, ETC.) POC PHONE NO.

SIGNATURE OF SPONSOR SPONSOR'S EMAIL DATE

PART III - TO BE COMPLETED BY AGENCY'S SECURITY OFFICER

MUST be completed for any visitor/guests requiring access to classified information.

***Signing this form is a release of Information (ROI)***

ORGANIZATION SECURITY OFFICER NAME AND AGENCY SIGNATURE DATE

CONTRACT NO. (IF APPLICABLE) CONTRACT EXPIRATION DATE (IF

APPLICABLE)

CURRENT INVESTIGATION ON FILE?

YES NO

INVESTIGATION TYPE

DATE OF INVESTIGATION INVESTIGATING AGENCY CLEARANCE LEVEL (if applicable) DATE GRANTED

SPECIAL ACCESS (IF APPLICABLE) SI - TK - G

DATE BRIEFED

HCS DATE BRIEFED