21._Attachment_D_Foreign_National_Data_Card.doc

Attachment D

WAPA Form 3000-72 Foreign National Data Card

DE-SOL-0006324

INSTRUCTIONS FOR PREPARING Foreign National Data Card for Unclassified Foreign Visits and Assignments to WAPA (WAPA F 3000-72#- 03-06)

Routing of Form:

FORMCHECKBOX

1. Requestor- Meeting host initiates the form at least 30-45 days before planned visit

FORMCHECKBOX

2. IT/Cyber Security Approval with any computer access

FORMCHECKBOX

3. Regional Manager (or Acting Official) for approval signature

FORMCHECKBOX

4. Original to Regional Safety and Security Office (The Safety and Security office reviews and sends to CSO-Security Office)

FORMCHECKBOX

5. CSO Security (Conducts required inquiries with DOE)

FORMCHECKBOX

6. Approval sent to Regional Safety and Security Officer

FORMCHECKBOX

7. Regional Safety and Security Officer notifies host and front desk personnel of approval/denial

To allow time for background checks, this form must be completed at least 30 days for non-sensitive countries visitors, and 45 days for visitors from sensitive countries.

For more information and a list of sensitive countries go to: http://www.cso.wapa.gov/cpo/3700/SECURITY/fva.htm

(Failure to complete this approval process may result in denial of visit.)

Section A – PERSONAL DATA INFORMATION

BLOCK 1.

Employee name: Last name; first name, middle name

BLOCK 2.

Select Male or Female: Place a check mark in the appropriate box

BLOCK 3.

Country of Birth: Spell out. No abbreviations

BLOCK 4.

City of Birth: Spell out. No abbreviations

BLOCK 5.

Home Address: Self-explanatory

BLOCK 6.

Date of Birth: Month/Day/Year

BLOCK 7.

Social Security Number: Self-explanatory

BLOCK 8.

Country of Citizenship: Spell out. No abbreviations

BLOCK 9.

Passport/Visa/Immigration Number: One must be supplied

BLOCK 10.

Country of Issue of Passport/Visa/Immigration Number

BLOCK 11.

Expiration Date: of above issued document Month/Day/Year

Section B – EMPLOYMENT DATA

BLOCK 12.

Current Employer/Business Name: Self-explanatory

BLOCK 13.

Business Address: Self-explanatory

BLOCK 14.

Business Phone: Self-explanatory

Section C – COMPUTER ACCESS & NETWORK CONNECTIVITY

BLOCK 15.

Do you have computer need: Answer yes or no

BLOCK 16.

Are you bringing a computer on site: Yes or no

BLOCK 17.

Do you need access to WAPA’s Information Systems: Yes or no

BLOCK 18.

Will you need to install software application to perform presentation(s) : Yes or no

BLOCK 19.

Do you require internet access: Yes or no

BLOCK 20.

Will the visitor/assignee have external devices (flash drive, removable drive, cd’s, disk, others) : Yes or no Section D – VISIT DATA INFORMATION

BLOCK 21.

Buildings/Sites/Areas to be Visited: Be specific (note: Must be escorted by host at all times)

BLOCK 22.

Request Date: Date host is submitting this request for approval

BLOCK 23.

Name and Signature of DOE Host: Must be a supervisor

BLOCK 24.

Contact # - Host’s #

BLOCK 25.

Is the host a U.S. Citizen: Yes/No

BLOCK 26.

Purpose of Visit: State clear purpose/be very specific

BLOCK 27.

Will sensitive or OUO be discussed? Describe what?

BLOCK 28.

Start Date of Visit: Month/Day/Year

BLOCK 29.

End Date of Visit: Month/Day/Year

BLOCK 30.

Authorized SES Manager Administrator Signature: Regional Manager or SES.

BLOCK 31.

IT/Cyber Security Office Approval: IT/Cyber signature and approval w/any computer access

BLOCK 32.

Authorized Approval Signature CSO Security Office –visit not approved without this signature

SECTION A – PERSONAL DATA

4. City of Birth:

9. Passport/Visa/Immigration Numbers:

11. Expiration Date:

SECTION B - EMPLOYMENT DATA

14. Phone:

SECTION C – COMPUTER ACCESS AND NETWORK CONNECTIVITY

15. Do you have computer needs? FORMCHECKBOX Yes FORMCHECKBOX No

16. Are you bringing computer on site? FORMCHECKBOX Yes FORMCHECKBOX No

17. Do you need access to WAPA’s Information System? FORMCHECKBOX Yes FORMCHECKBOX No

18. Will you need to install software applications to perform presentation(s)? FORMCHECKBOX Yes FORMCHECKBOX No

19. Do you require internet access? FORMCHECKBOX Yes FORMCHECKBOX No

20. Will the visitor/assignee have external devices (flashdrive, removable drive, cd’s, disks, others) that they will be bringing on site? FORMCHECKBOX Yes FORMCHECKBOX No

SECTION D - VISIT DATA

21. Buildings/Sites to be Visited:

Yes FORMCHECKBOX No

26. Purpose of Visit/Assignment (be very specific):

27. Will sensitive or Official Use Only (OUO) information be discussed? FORMCHECKBOX Yes FORMCHECKBOX No If yes, what? (be specific)

30. Authorized SES Manager Administrator - Signature:

Date:

31. IT/Cyber Security Office Approval - Signature:

Date:

32. Security Office Approval - Signature:

Date: