SCI_Pre_Screen_Questionaire_DEC_2017.pdf

UNCLASSIFIED//FOR OFFICIAL USE ONLY

This document and/or any attachments may contain Privacy Act (1974 as amended) information which must be protected IAW 5 USC 301, DoD Regulation 5200.2.R, NSA/CSS Policy 1-34, and DIA Manual 50-8, or be removed prior to further disclosure. This information is: For

Official Use Only (FOUO). Privacy Sensitive: Any misuse or unauthorized access may lead to disciplinary action.

DEPARTMENT OF DEFENSE

UNITED STATES CYBER COMMAND

9800 SAVAGE ROAD, SUITE 6477

FORT GEORGE G. MEADE, MARYLAND 20755

US CYBER COMMAND SPECIAL SECURITY OFFICE PRE-SCREEN INTERVIEW QUESTIONAIRE

Name/Rank/Service/SSN: ________________________________________________________

All “YES” answers require a detailed explanation on a separate attachment for each YES answer. Select the appropriate answer via the drop down menu.

1. Has your marital status changed since you completed your SF-86 (marriage, divorce, cohabitation)?

2. Do you have any immediate family member that were born outside of the U.S. (regardless of current citizenship status)?

3. Do you have any immediate family members that are not U.S. citizens (spouse, parents, siblings, children, in-laws, cohabitants)?

4. Do you or any of your immediate family members claim a dual citizenship with another country?

5. Do you maintain a close and/or continuing association with anyone that is not a U.S. Citizen?

6. Did you maintain a close and/or continuing relationship with anyone who was not a U.S. Citizen where you listed that person on a previous SF-86? If yes, provide the name(s), date and reason(s) why this relationship ended.

7. Do you or any immediate family members have foreign property or foreign financial interests?

8. Have you visited any foreign countries in the last seven years?

9. Are you now or have you ever been a member of any organization, associated with, or contributed to any movement or group that advocates the overthrow of the U.S. Government?

10. Are you now or have you ever been associated with group or anyone who was a member of any organization, associated with, or contributed to any movement or group that advocates the overthrow of the U.S. Government?

11. Have you consulted with a mental health professional in the last seven years?

a. Answer NO if the consultation with a mental health provider is listed below:

• Strictly martial, family, grief counseling not related to violence by you; or

• Strictly related to adjustments from service in a military combat environment (PTSD); or

• As a victim of sexual assault, strictly in relation to the sexual assault.

12. Have you been arrested or had any adverse involvement with any law enforcement agencies in the last seven years?

13. Are there currently any charges pending against you for any criminal offense(s)?

14. Have you ever had any adverse involvement with alcohol (e.g. DUI, treatment, counseling, drunk in public, accident where alcohol was a factor, arrest, etc.)?

15. Have you used, possessed, bought, sold, or transferred any illegal drugs or illicit substances in the last seven years?

16. Have you had your security clearance and/or access suspended, denied or revoked in the last Seven years?

This document and/or any attachments may contain Privacy Act (1974 as amended) information which must be protected IAW 5 USC 301, DoD

Regulation 5200.2.R, NSA/CSS Policy 1-34, and DIA Manual 50-8, or be removed prior to further disclosure. This information is For Official Use Only

(FOUO). Privacy Sensitive: Any misuse or unauthorized access may lead to disciplinary action.

USCYBERCOM SSO Form 2

17. Have you had any bills referred to a collection agency in the last seven years?

18. Have you experienced financial difficulties in the last seven years to include wages garnishment, repossessions, tax liens, judgments, or bankruptcy?

19. Have you ever been the subject of any security inquiry/investigation?

20. Have you ever been involved in the loss of, compromise of, or mishandling of classified information?

21. Have you ever been involved with the misuse of any information technology system?

22. Have any incidents occurred, not mentioned above, which may reflect upon your ability to maintain your clearance and access?

23. If you currently hold an active security clearance, has any information (not listed above) changed since you completed your last SF-86 and/or in the last seven years?

24. Have you ever worked at and/or had access to any NSA site?

25. Have you ever been issued any IC badge, or any other retention SI//TK badge by the NSA?

26. Have you ever been issued any IC badge by any other US Government agency?

27. Are there any other items, issues, and/or incidents that may have an effect on your ability to retain your SCI clearance, or obtain/maintain access to NSA?

I attest that all answered information on this form is truthful and accurate along with any attachments explaining any YES answers. I further attest that I did not in any way, with or without purposeful or negligent intent, provide any misleading, incorrect, or false information. I further understand that any false or misleading answers shall subject me to any applicable criminal and/or UCMJ violations and other/or administrative actions.

Signature: _______________________________ Date: _________________________

Reviewed by SSO: ______________________________________ rmthom8 Typewritten Text rmthom8 Typewritten Text rmthom8 Typewritten Text (Not a background investigation/reinvestigation for a security clearance.)

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