Attachment J-12 Security Form for Temporary Contractors.docx
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- Residential Drug Treatment Services
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About this file
This is a security background check form used by the Court Services and Offender Supervision Agency for the District of Columbia (CSOSA) for all temporary contractor personnel performing work under CSOSA contracts. The form is completed jointly by the Contracting Officer or Contracting Officer Representative and the contractor applicant, then submitted to the CSOSA Office of Security for background investigation and approval before work commences.
The form is divided into two sections: Part I is completed by the CO or COR and captures contract-related information including the program office, contract number, applicant name, position title, position description, assignment duration, and access requirements (NCIC/WALES and CSOSA Network access). Part II is completed by the applicant and collects personal information including full name, aliases, contact information, home address, demographic data (sex, race, date of birth, place of birth), Social Security number, and U.S. citizenship status. The applicant must disclose whether they have been fired, quit under threat of termination, or left by mutual agreement following misconduct allegations in the past seven years, and whether they have been arrested for, charged with, or convicted of any offense in the past seven years (excluding traffic fines under $150). The applicant must certify that all information provided is true and complete. Upon receipt, CSOSA's Office of Security conducts a background check and notifies the CO when the individual is approved to begin work.
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Court Services and Offender Supervision Agency for the District of Columbia
Attachment J-8: SECURITY FORM FOR TEMPORARY CONTRACTORS
This form is to be used for all contractor personnel performing work under contract with CSOSA. It is to be completed as indicated and returned to the Office of Security by the Contracting Officer. Upon receipt of the completed documentation, the Office of Security will conduct a CSOSA background check and will notify the CO when the individual is approved to begin work.
PART I – TO BE COMPLETED BY THE CONTRACTING OFFICER (CO) OR CONTRACTING OFFICER REPRESENTATIVE (COR)
COR Program Office: Tel: Date:
· COR:
· Position Sensitivity:
· Desired Performance Start Date:
· Contractor Name:
Contract Number:
Applicant Name:
· Position Title:
· Position Description:
· Duration of Assignment:
□NCIC/WALES Access: □Yes □No
□CSOSA Network Access: □Yes □No
Prepared By:
Print Name Signature & Date
CSOSA-SEC-0010 1 Revision: 10/2013
PART II – TO BE COMPLETED BY THE APPLICANT
1. Full Name (Last, First, MI)
2. Other Names Used (Maiden and Alias)
3. Telephone Number(s) where you can be reached
4. Home Address (Street, City, State, and Zip Code)
5. E-mail Address
6. Sex Male Female
7. Race:Black Not-Hispanic
8. Date of Birth (Mo/Day/Year)
9. Place of Birth (City, State, Country)
10. Social Security Number
11. U.S. Citizenship By Birth Naturalized Other
12. In the last seven years, have you been fired from a job, quit after being told you would be fired, or left by mutual agreement following allegations of misconduct or unsatisfactory performance?
Yes No If your answer is “Yes,” explain below:
Date Reason Employer’s Name & Address
13. In the last seven years, have you been arrested for, charged with, or convicted of any offense(s)? (Leave out traffic fines of less than $150).
Yes No If your answer is “Yes,” explain below:
Date Charge Police Agency Disposition
I certify that the statements made by me on this form are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that this information will be used to conduct records checks for the purpose of either paid or unpaid employment with the Court Services and Offender Supervision Agency.
Signature Date
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