Security Risk Review Appendix 3 - AFRL Privacy Act for Covered Individuals Fillable.pdf
PDF 107 KB Posted
- Attached to
- Trusted and Elastic Military Platforms and Electronic Warfare (EW) System Technologies (TEMPEST) Federal contract opportunity
- Solicitation number
- FA8650-20-S-1958
About this file
This is a Privacy Act Statement form from the Air Force Research Laboratory that must be completed by covered individuals and their institution's authorized representative. The form outlines the authority, purpose, and routine uses of information collected in connection with Federal Grants, Cooperative Agreements, Contracts, and Other Transaction Agreements.
The document explains that providing information is voluntary but failing to comply with disclosure requirements under 42 U.S.C. § 6605 may result in rejection of applications. The form requires signatures from both the covered individual and the institution's authorized representative, along with printed names, dates, and institution name. The form is an administrative template for collecting privacy acknowledgments and does not contain specific requirements for products or services.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| TEMPEST_ARA_FA8650-20-S-1958 July 2026.pdf | ||
| TEMPESTARAFA8650-20-S-1958 APRIL 2026.pdf | ||
| TEMPESTARAFA8650-20-S-1958 01-28-2026.pdf | ||
| TEMPESTARAFA8650-20-S-1958 11-19-25.pdf | ||
| TEMPESTARAFA8650-20-S-1958 09-26-25.pdf | ||
| TEMPEST-ARA-FA8650-20-S-1958 04-1-25.pdf | ||
| TEMPEST ARA FA8650-20-S-1958 - FINAL.pdf | ||
| Security Risk Review AFRLI 61-113.pdf | ||
| Security Risk Review Appendix 1 - Security Program Questionnaire.pdf | ||
| TEMPEST ARA FA8650-20-S-1958 - FINAL.pdf | ||
| Security Risk Review Appendix 2 - Research and Related Senior and Key Person Profile Worksheet.pdf | ||
| Model_Contract_FA8650-20-S-1958.pdf | ||
| TEMPEST_ARA_FA8650-20-S-1958_-_FINAL.pdf |
Show all 13
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Text version
Privacy Act Statement Air Force Research Laboratory
Authority: Government Paperwork Elimination Act (Pub. L. 105-277, 44 U.S.C. 3504); Executive Order 12372, Intergovernmental review of Federal Programs (47 FR 30959); 42 U.S. Code § 6605 – Disclosure of funding sources in applications for Federal research and development awards; Public Law 117-167, CHIPS and Science Act; Public Law 116-92, National Defense Authorization Act for Fiscal Year 2020;
Public Law 116-283, National Defense Authorization Act for Fiscal Year 2021; 5 U.S.C. 9101, Access to Criminal History for National Security and Other Purposes 5 CFR §1320.8, Agency collection of information Responsibility; 18 U.S.C. § 1001, False Statements, Concealment; E.O. 13478, Amendments to Executive Order 9397 Related to Federal Use of social Security Numbers; NSPM-33, National Security Presidential Memorandum 33 on National Security for United States Research and Development; DoD-D 5240.01, DoD Intelligence Activities; DoDI 5200.02, Department of Defense Personnel Security Program; DODI 5205.87 Mitigating Risks Related to Foreign Ownership, Control, or Influence for Covered DOD Contractors and Subcontractors; Air Force Research Laboratory Instruction 61-113, Science and Technology Protection for the Air Force Research Laboratory;
Purpose: The information collected may be used in processing, investigating, and maintaining records relevant to Federal Grants, Cooperative Agreements, Contracts, Other Transaction Agreements or other research related agreements awarded by the Department of the Air Force. Records in these systems will be used to ensure Department of the Air Force sponsored and/or awarded federal grants, cooperative agreements, contracts, Other Transaction Agreements and/or benefits are awarded to responsible parties, entities, and individuals.
Routine Uses: To contractors, grantees, experts, consultants, students, and others performing or working on a contract, grant, cooperative agreement, other transaction or other assignment for the Federal Government when necessary to accomplish an agency function.
To the appropriate Federal, State, local, territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law, whether criminal, civil, or regulatory in nature.
DoD Blanket Routine Use (http://dpcld.defense.gov/privacy)
Effect of not providing information: Providing information to the Department of the Air Force is voluntary. However, 42 U.S. Code § 6605, which imposes certain disclosure requirements in connection with Federal research and development awards, provides various enforcement mechanisms for non-compliance to include civil or criminal remedies. One such mechanism, which the Department of the Air Force intends to pursue here, is rejection of such applications.
Proposal Title: ____________________________
Acknowledgment of consent:
Covered individual (Signature): ______________________________ Date: ___________
Covered individual (Name print): ______________________________
Institution’s Authorized Representative (Signature): _______________________ Date: ___________
Institution’s Authorized Representative (Name print): ______________________________
Institution Name: _______________________________ http://dpcld.defense.gov/privacy
| Proposal Title: |
| Covered individual Name print: |
| Institutions Authorized Representative Name print: |
| Institution Name: |
| Date: |
| Date2: |
File details come from the government source that posted it. Updated .