Contractor Information Worksheet

*Use GSA Form 850 for ARRA Temporary Contractors For Official Use Only

Contractor Information Worksheet (CIW) Version 2 Pg. 1 of 2

Type Contractor (Definitions on Pg. 2)

CONTROL Forms.OptionButton.1 \s ARRA Long Term

Investigation Preference

Priority (Option available for MBI / LBI / BI only)

Sponsoring Office Symbol

GSA Region (Options on Pg.2)

1. Contract Employee Information

Name (Last/Family)

First (Given)

Middle (or NMN if none)

Suffix

Social Security #

Date of Birth

Place of Birth (POB): City

POB: State

Country

Sex

Home Address Street e-Mail

Address Street (line 2)

Phone Number (Day)

Phone Number (Cell)

City

State

Zip

Position (Job) Title

FORMCHECKBOX

IT System Administrator

Prior Investigation

Investigation Date

Prior Investigation Point of Contact (POC)

U.S. Citizen

Non-U.S. Citizens Only: Port of Entry City and State

Date of Entry

FORMCHECKBOX

< 3 Yrs. U.S. Resident Alien Registration #

Citizenship Country

2. Contact Information

Company Name

Company is:

If Sub, Name of Prime

Task Order (TO) / Delivery Order (DO) Number (Enter Contract Base Number if TO / DO is Not Applicable)

Contract Number Type

Contract Start Date

Contract End Date

FORMCHECKBOX

Has Option Yrs. Or End Date TBD

Company Point of Contact (POC) Name

POC Phone Number (Day)

POC Email Address

3. Project/Work Location Information (Government site where contractor is working)

GSA Building Number

Building Name

Building Address

4. Type of Investigation Requested for: HSPD-12 Credential

5. Requesting Official (Sponsor) Information

Sponsor’s Name

Title

FORMCHECKBOX

Is COR/COTR

Email Address

Phone Number (Day)

Date Forms Were Reviewed

Comments

6. DHS Federal Protective Service CSA (Staff use only) Personnel Security Investigation:

OPM PIPS Inv

Status e-QIP Invitation #

Date e-Mail Sent

[ ] Release Form

[ ] CER

[ ] Medical Release

[ ] GSA Form3665

[ ] FD 258

[ ] CS Case

[ ] FD 258 RAP

[ ] Just Date Received

[ ] Reviewed

[ ] Scan/TIF

Date Sent to OPM

Suitability Decision

Preliminary Date

[ ] Unfavorable

[ ] Favorable

Final Date

[ ] Unfavorable

[ ] Favorable Notify Preliminary Decision

[ ] Email: hspd12.security@gsa.gov

[ ] Email: COTR/Requesting Official

[ ] Email: Subject

[ ] Email: Subject’s Company

Notify Final Decision

[ ] Email: hspd12.security@gsa.gov

[ ] Email: COTR/Requesting Official

[ ] Email: Subject

[ ] Email: Subject’s Company

Contractor Information Worksheet Instructions Version 2 (Pg. 2 of 2)

Type Contractor Definitions:

· PBS Contractor: PBS building support contractor

· Embedded: ‘Embedded’ or white collar. Formerly identified as Non-PBS Contractor in previous versions of CIW.

· Child Care: Child care worker

· External: Does not access GSA building or IT systems

GSA Region Options: Region 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, NCR, or CO

Privacy Act Notice In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by the Federal Property and Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; O. 9397 Disclosure of the information is voluntary. This form will be used as a means to prepare and issue a credential or pass. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit. If the individual does not provide some or any part of the requested information, the employee will not be issued a credential and will not be allowed to enter a GSA-controlled building after normal working hours or when the building is under security.

Submission Information

1. Ensure all information is complete

2. Return this form to your Supervisor/Contracting Officer

3. If the contractor opted to fill out a "Hard Copy" version of the SF-85P, please complete the background investigation package and send it along with Contractor Information Worksheet. SF-85P is available on GSA InSite

4. MAILING INSTRUCTIONS:

If the contractor is a Non-PBS GSA Contractor background investigation package should be mailed to the FPS-HQ Office

OR

If the contractor is a PBS contractor, background investigation package should be mailed to respective FPS Regional Contract Suitability Adjudication Field Offices listed below:

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