Exhibit H - DHA Physical Security Checklist.pdf

Exhibit H – DHA Physical Security Checklist

ATAMMC PWS Exhibit H - DHA Physical Security Checklist

DHA PHYSICAL SECURITY CHECKLIST

(MEDICAL FACILITIES)

GENERAL YES NO

1. Ensure the end -of-day security checks are conducted and documented on the SF 701.

(DoDM5200.01V-3, Encl. 2, Para 9) (Minor)

ADMINISTRATIVE KEYS and LOCKS

** In accordance with Naval Facilities Engineering Service Center User’s Guide (DOD Lock Program) (UG-2040-SHR) and AR 190-51 Appendix D which is referenced in UG-2040-SHR)

YES NO

1. A primary/alternate key custodian will be appointed in writing. (UG-2040-SHR CHAPT 3, Sect. 2, Para A) (Major)

2. All personnel authorized to receive keys, including the key custodians, will be listed on a current key access roster. (UG-2040-SHR CHAPT 3, Sect. 5, Para 1a) (Minor)

3. A Key Control Register will be utilized to sign for all keys. (UG-2040-SHR CHAPT 3, Sect. 5, Para 4A 3) (Major)

4. A record of the semiannual key/lock inventory will be maintained for 90 days or until the next inventory is conducted, then destroyed. (AR 190-51,App D, Para D-6b) (Minor)

5. The key control register will be stored in a locked container out of public view. (UG- 2040-SHR CHAPT 5, Sect. 2, Para D) (Minor)

6. The admin key depository/container will be constructed of at least 26 gauge steel. (UG- 2040-SHR CHAPT 5, Sect. 2, Para D) (Minor)

7. If the key depository/container weighs less than 500lbs it will be secured to the structure. (UG-2040-SHR CHAPT 4, Sect. 2, Para B6) (Minor)

8. All keys to include backup, reserve and any keys securing government property will be properly secured. (UG-2040-SHR CHAPT 5, Sect. 2, Para C 1&2) (Minor)

9. Unauthorized locks will not be used to secure government property.

( UG-2040-SHR CHAPT 4 Sect. 3, Para A, Fig. 4-7 & Table 4-3) (Minor)

10. Key depository is not located in a room where it is kept under surveillance around the clock or in a room that can be locked when unoccupied. (UG-2040-SHR CHAPT 4, Sect.

4, Para B3) (Minor)

11. Locks were not replaced or recorded when it is determined that a key is missing. ( UG- 2040-SHR CHAPT 3, Sect. 2, Para D7) (Major)

12. A master key/lock inventory list will be maintained listing all keys and lock serial numbers of all keys, number of keys for each lock and their locations. (AR 190-51, App D, Para D-6d.(1)-(6) and UG-2040-SHR CHAPT 4, Sect. 4, Para B3) (Minor)

13. Keys/locks which do not have a serial number have not been inscribed with one. (This includes key serial numbers with spare keys in multiples of 3 or more keys and additionally marking them with -1, -2 or –a, -b, etc) ( UG-2040-SHR CHAPT 3, Sect. 2, Para D3) (Minor)

14. A key and lock inventory, of all keys assigned to the activity will be conducted by serial number initially and by serial number semiannually thereafter. ( UG-2040-SHR CHAPT 3, Sect. 2, Para A) ) (Major)

PHARMACIES

1. Are Pharmacies designated as a “Restricted Area”? (DOD 5200.8R CHAPT 3 C3.2.4) (Major)

2. Are all incidents of suspected theft, loss, illegal entry, open or unlocked facilities or containers, and other incidents of suspicious origin being reported immediately to designated authorities? ( CFR 21, Part 1301, Part 301.76(b) (Major)

3. Are pharmacy entry/exit doors locked at all times, except for actual entry and exit of authorized personnel? ( CFR 21, Part 1301, Para 301.72(b)(3)(ii) (Minor)

4. Do the Controlled Medical Substances Vault meet the construction standards for doors, windows, wall, ceilings, and floors as appropriate for the applicable risk level (CFR 21, Part 1301, Para 301.72(b)(3) (ii) (Major)

5. Access to Controlled Medical Substances areas is strictly controlled? (CFR 21, Part 1301, Para 301.72(a)(2) and (DoDM5200.01V-3, Appendix to Encl. 3, Para 3a)

6. Have local files checks been conducted for personnel authorized unaccompanied access to the Controlled Medical Substances Vault? ( CFR 21, Part 1301, Part 301.76(a)

7. Items identified as Schedule II will be secured in an approved safe or vault secured with an GSA approved vault door or high security padlock. (CFR 21, Part 1301, Para 301.72(b)(2) (Major)

8. Vault, if operations require it to remain open for frequent access, is equipped with a “day-gate” which is self-closing and self-locking, or the equivalent, for use during the hours of operation in which the vault door is open. (CFR 21, Part 1301, Para 301.72(a)(3)(iii) (Major)

9. Is the vault protected by 2 means of detection; Perimeter Door – balanced magnetic switch and an interior motion sensor(s). (DoDM5200.01V-3, Appendix to Encl. 3(3),(4)

10. Are signs posted indicating that IDS is in use for the activity?

11. IDS will be provided for all vaults in service after 1 September 1971. (CFR 21, Part 1301, Para 301.72(a)(2) (Major)

12. The controlled substances storage areas shall be accessible only to an absolute minimum number of specifically authorized employees. When it is necessary for employee maintenance personnel, nonemployee maintenance personnel, business guests, or visitors to be present in or pass through controlled substances storage areas, the registrant shall provide for adequate observation of the area by an employee specifically authorized in writing. (CFR 21, Part 1301, Para 301.72(d) (Minor)

13. If there is a vault, authorized individuals will be issued IDS PIN numbers and records will be maintained for 90 days after the removal of the individual. (DoDM5200.01V-3, Appendix to Encl. 3, Para 3(7) (Minor)

14. Access to records and information concerning PINs will be restricted.

(DoDM5200.01V-3, Appendix to Encl. 3, Para 3(6) (Major)

15. An SF 702 will be used to record vault opening/closing and periodic security checks.

DoDM5200.01V-3, Appendix to Encl. 2 Para 9. (Minor)

16. Keys and Key Control will be in accordance with (UG-2040-SHR) and AR 190-51 CHAPT4 and Appendix D

SAFES

1. Combinations to security containers, vaults, and secure rooms will be changed: when placed in use, whenever an individual knowing the combination no longer requires access, when the combination has been subject to possible compromise, at least once annually or when taken out of service. (When taken out of service, built–in combination locks will be reset to the standard combination 50–25–50; combination padlocks will be reset to the standard combination 10–20–30). ( DoDM5200.01V-3, Encl. 2, Para 11b) (Major)

2. The SF 700 (Security Container Information) was not annotated properly or the SF 700 was not present. (DoDM5200.01V-3, Encl. 3, Para 10a&b). (Major)

3. Is Part II of the SF 700 stored in a separate location than the security container?

(DoDM5200.01V-3, Encl. 3, Para 10a&b) (Minor)

ANTITERRORISM

1. Does the activity have a current Risk Assessment? (DOD O-2000.12H, Chapter 8, Para C8.1)

2. Does the activity have or have access to their next command’s Antiterrorism Plan and has that plan been revised to fit the needs of the clinic/activity? (DOD O-2000.12H, Chapter 8, Para C9.1)

3. Are the activity’s program areas reviewed at least annually and the review documented? (DOD O-2000.12H, Chapter 8, Para C15.1.1)

4. Do perimeters, parking spaces, roads, and trash containers meet the standoff distances required by Appendix B UFC-010-01. (UFC-010-01, Appendix B, Para B-1.1 and Table B-1 & B-2)

5. Does the conventional wall construction of the building meet the minimum standoff distance or has an engineer conducted a blast analysis? . (UFC-010-01, Appendix B, Para B-1.1.2 & 1.1.3)

6. Do utility equipment and trash containers meet the standoff distance prescribed in appendix B or if not; have they been hardened on all sides with fencing and with a top made of the same material. . (UFC-010-01, Appendix B, Para B-1.2. & B-1.2.3)

7. Does the activity’s landscaping provide clear zones which do not impede line-of-site from building windows, doors, and fence lines? (UFC 4-022-01 Sect 6, Para6-21)

8. Is access to the activity’s building controlled by a personnel ID/access roster system?

(DODI 2000.12p, Sect 4, Para l & m)