WAPA_Background_Check__NEW.pdf

Attachment 1

Revised 11/12/2015

WESTERN AREA POWER ADMINISTRATION

BACKGROUND CHECK INSTRUCTIONS FOR CONTRACTOR PERSONNEL

The performance of this contract requires that employees of the contractor must comply with the requirements of undergoing an appropriate background investigation in order to gain access to Western (physical and/or logical access).

Western contractors must complete the background check and badging requirements prior to coming on board with Western. All new Contractor Employees are required to complete the information as required and submit it to Western Area Power Administration no later than 14 days prior to the new employee’s reporting date. If the background check paperwork and the badge enrollment are not completed the contractor will not be able to start work.

This information must be complete and legible or the contractor will not be processed. The form must be submit by the Western Contracting Officer (CO) or Contracting Officer Representative (COR) to the Corporate Service Office (CSO) Office of Security and Emergency Management (OSEM) via e-mail to pgarcia@wapa.gov, Gatsiopoulos@wapa.gov and Cooprider@WAPA.GOV.

Section A: To be completed by Contract Employee:

1. LAST NAME: 2. FIRST NAME: 3. MIDDLE NAME:

4. DATE OF BIRTH: 5. PLACE OF BIRTH (City/State): 6. SOCIAL SECURITY NUMBER:

7. EMPLOYEE’S E-MAIL ADDRESS:

*Full name of employee (middle name included, if no middle name please indicate “NMI”)

Section B: To be completed by Contract Lead:

8. CONTRACTOR’S COMPANY NAME:

9. EMPLOYEE’S POSITION TITLE: 10. LOCATION EMPLOYEE WILL BE WORKING (REGION IF POSSIBLE):

Section C: To be completed by Western Area Power Administration:

11. CONTRACTING OFFICER REPRESENTATIVE’S NAME, PHONE NUMBER AND E-MAIL ADDRESS:

12. LEVEL OF BACKGROUND INVESTIGATION REQUESTED – MARK ONE ( A SELECTION IS REQUIRED):

LOW ___________ MODERATE __________ HIGH ___________

SAC ___________

(Optional Check for Contractors working under 180 days)

Badge Only __________ (Contractors working under 180 days but require network access)

13. CONTRACT EMPLOYEE REQUIRES GOVERNMENT ISSUED BADGE IF: WORKING 180 DAYS OR MORE AND/OR

REQUIRING REMOTE ACCESS REGARDLESS OF AMOUNT OF TIME WORKING

YES _____ NO _____ ** SPECIAL NOTE: Contractors working under 180 days that require having network/computer access must undergo the badging process and obtain a badge. The badge is required to log into the computer.

Privacy Notice: 42 U.S.C. 7101, 50 U.S.C 2401 and Public Law 93-579 permit collection of the data requested on this form. The information is used to determine suitability for the issuance of a DOE security badge as well as suitability to work on a Government facility. The information will be used to identity proof and register Applicants as part of the Personal Identity Verification process. Providing this information is voluntary; however, failure to submit this information may result in denial of employment serving as a Government Contractor.

Grover Bray

X

Parker DAM location, Contract DE-WA000_ _ _ _

602-605-2711 Bray@WAPA.GOV mailto:pgarcia@wapa.gov mailto:Gatsiopoulos@wapa.gov