Attch 5 - Draft CSCS Form DOE F 470.1.pdf

1. CSCS No.: 2. Previous CSCS No.: 3a. Reason for Action: (Check one) Add Change Terminate

b. Item Numbers Modified:

4. This Specification is for: (Complete as applicable) 5. Specification Is: (Complete as applicable)

a. Contract or Other Number Solicitation

b. Contract Number End Date:

(estimated)

c. Contract Number of Prime

End Date: (Complete if registering or soliciting a subcontract)

(estimated)

a. Original (Complete date in all cases) Date:

b. Revised (Supersedes all previous specifications) Date:

c. Certificate of Possession.

Retention of Classified Matter is Authorized Until

Date:

Date:

d. Final

Certificate of Non-Possession or Equivalent.

Date:

Date:

6. General Identification of this Procurement

7. Contractor

a. Facility Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

8. Prime Contractor (Complete if registering or soliciting a subcontract)

a. Facility Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

9. Actual Place of Performance (DOE Facilities) (Attach additional entries as necessary)

a. Facility Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

Actual Place of Performance (NON-DOE Facilities) (Attach additional entries as necessary)

a. ID Code b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

10. Clearance and Storage

a. Classification of Matter to be Accessed:

b. Level of Storage Required at Contractor Facility in Block 7a:

c. Level of Storage for the Performance of this Contract:

d. Access Authorization/Security Clearance:

Q L T S C

11. This Contract Will Require Access To:

12. In Performing This Contract, The Contractor Will:

Have Access to Classified Information Only at Another Contractor’s Facility or a Government Activity

Generate Classified Matter

Perform Services That Require Unescorted Access to Security Areas

Have Access to U.S. Classified Information Outside the U.S., Puerto Rico, U.S. Possessions and Trust Territories

DOE F 470.1

(02/2018) Replaces DOE F 470.1 (09/2014) All Other Editions are Obsolete

U.S. Department of Energy

CONTRACT SECURITY CLASSIFICATION SPECIFICATION (CSCS) -1-

Contract Type

TSRD

CRD

SFRD SNSI

CNSI U

TSFRD

CFRD

TSNSI SRD

TSRD TSFRD TSNSI SRD SFRD SNSI

CRD CFRD CNSI U

TSRD TSFRD TSNSI SRD SFRD SNSI

CRD CFRD CNSI U

Approved National Interest Determination (Contractor Facility under FOCI Mitigation)

OTHER DCI CAVEATS

NATO

SCI

CNWDI

WD/SIGMAS:

OTHER:

COMSEC

FGI

Other (Specify):

Receive Classified Matter

Fabricate, Modify or Store Classified Items (e.g., Hardware or Substances)

Be Authorized to Use the Services of the Office of Scientific and Technical Information to Receive Classified Matter

Require a COMSEC Account

Be Authorized to Use the Defense Courier Service pecynski Highlight pecynski Highlight

DOE F 470.1

(02/2018) Replaces DOE F 470.1 (09/2014) All Other Editions are Obsolete ‒ 2 ‒

13. Classification Guidance

The classification guidance needed for this classified effort is identified below. NOTE: Guidance which is in itself classified should be referenced here and provided under separate cover.

14. Security Requirements

Security requirements are established for this contract and are identified in the following contract clauses.

15. Surveys

DOE Surveying Office Is

Elements of this contract are outside the survey responsibility of the Cognizant Security Office and/or the Surveying Office.

No Yes (Identify specific areas and provide explanation/justification for each)

16. Certification and Signature. Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified contract. All questions shall be referred to the official named below:

a. Typed Name of Procurement Request Originator b. Title and Organization c. Telephone (include Area Code)

d. Address (include Zip Code) e.

Signature Date

17. Typed Name of Contracting Official

Signature Date

18. Other Approvals

Signature Date

19a. Typed Name of Local Security Officer

b. Responsible Office Signature Date

20.

21. General Comments:

a. Typed Name of Classification Officer (Approval of Block 13)

b. Typed Name of Special Security Officer, Office of Intelligence & Counterintelligence (Approval of Block 11 (SCI))

Signature Date

DEAR 952.204-2 Security Requirements

DEAR 952.204-70 Classification/Declassification

DEAR 952.204-73 Facility Clearance (Solicitation)

DEAR 970.5204.1 Counterintelligence (for Management Contracts ONLY)

Required Distribution Contractor Subcontractor Cognizant Security Office

Administering Contracting Officer Surveying Office if Different than Cognizant Security Office Others, as Necessary

DOE F 470.1

(02/2018) Replaces DOE F 470.1 (09/2014) All Other Editions are Obsolete ‒ 3 ‒

9. Actual Place of Performance (DOE Facilities)

a. Facility Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

a. Facility Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

a. Facility Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

9. Actual Place of Performance (NON-DOE Facilities)

a. ID Code b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

a. ID Code b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

a. ID Code

b. Name, Address, and Zip Code c. Cognizant Security Office (Name, Address, and Zip Code)

PO Box 5400 Albuquerque, NM 87116