J.12_CMS_730A_Request_for_Physical_Access_to_CMS_Facilities.pdf

Form CMS-730A (11/03) (ALL OTHER EDITIONS OBSOLETE)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Social Security Number Phone Number (include extension)

Applicant’s Name (Last) (First) (Middle) (Print Clearly)

Contract Company Name (if subcontractor, include parent company)

PART I — TO BE COMPLETED BY REQUESTOR (Please type or print)

PART II — REASON FOR APPLICATION (Required) PART III — TYPE OF BADGE (Required for initial issuance only)

Reason:

❏ Change in job requirements ❏ Renewal

❏ Initial Issuance ❏ Replacement due to loss

❏ Name change from (Print former name below):

Type:

❏ Contractor ❏ Security

❏ Former HCFA/CMS Employee (Ethics Officer Signature required)

PART IV — ELECTRONIC ACCESS (required for all accesses to CMS secured areas) (Pin # Selection - Pin # (4 digit) ___ ___ ___ ___

ELECTRONIC ACCESSES (check all accesses needed to perform duties): ❏ ADP Satellite Room(s) — (specify room numbers)

❏ CMS Data Center ❏ Voice Data Switch ❏ LBD ADP Room ___________________ ______________________

❏ ITF Room ❏ Mailroom ❏ LBD Voice Room ___________________ ______________________

❏ Secure Server ❏ ASG Siteman ❏ Gov. Court ___________________ ______________________

❏ CDC Warehouse ___________________ ______________________

❏ ’S’ Sign-in Authority (*see bold statement in Privacy Act on reverse side) ___________________ ______________________

PART V — ELECTRONIC ACCESS JUSTIFICATION PART VI — PROPERTY PASS INFORMATION

(Required for all accesses requested in PART IV)

Electronic Access Justification Property Description

1 ____________________________________________________

2 ____________________________________________________

Property Serial No.

1 ____________________________________________________

2 ____________________________________________________

OOM/SSS Authorization

PART VII — BACKGROUND INVESTIGATION

❏ Non-Sensitive LEVEL 1 ❏ Public Trust LEVEL 5 ❏ Public Trust LEVEL 6

PART VIII — AUTHORIZATIONS (required)

Project Officer – (Print name clearly) Phone Number

Project Officer - Signature Date

Note: You are required to collect Government issued ID and/or Access Card(s) at end of Contractor’s project.

Contract Officer – (Print name clearly) Phone Number

Contract Officer – Signature Date

Contract Number

Contract Expiration Date

REQUEST FOR PHYSICAL ACCESS TO CMS FACILITIES (NON-CMS ONLY) Date ________________________

PRIVACY ACT ADVISORY STATEMENT

As required by 5 U.S.C. 552a (The Privacy Act of 1974 and Executive Order No.9397), you are advised that the Centers for Medicare & Medicaid Services (CMS) is authorized to collect the data on this form by 63 Stat. 390, 40 U.S.C. 86(c), and 41 C.F.R. 101-20.111. Your response to the questions on this form is not required by law. However, if you do not provide this information, your application for privileges may be denied or delayed in processing. No disclosure of this information will be made unless required by law or with written consent.

The information on side 1 of this form is collected and maintained under the authority of 41 CFR 101-20.302, “Conduct on Federal Property” and “OMB Circular A-123, Internal Control Systems.” This information is used for assigning, controlling, tracking and reporting permanently or temporarily issued unescorted access into a Government Facility. The Privacy Act prohibits disclosure of information from records protected by the statute, except in limited circumstances. Public Law 93- 579, the Privacy Act of 1974, provides penalties of up to $5,000 for willful disclosure of material in any manner to any person or agency not entitled to protected information, which includes the utilization of your badge to sign-in individuals or groups which you do not escort throughout the complex. *Your signature authorizing admittance to anyone into any CMS facility means that you are responsible for the whereabouts and conduct of said person(s). Please be advised that all persons being signed in to the CMS facilities are considered visitors. ONLY Visitor badges will be issued. If any visitor is found unescorted within the complex, they may be escorted off the premises. By signing below you acknowledge and accept these requirements necessary for this privilege. If you are found to be in vio-lation of any of these requirements, this privilege may be revoked.

The information you furnish on this form will be maintained in the Records of Individuals Issued Card Key System (RICKS) and the CMS Employee Pass File (EMPASS) Systems of Record and may be disclosed as a routine use disclosure under those uses established for this system as published in the Federal Register and as CMS may establish in the future by publication in the Federal Register.

By signing below you accept the responsibility of being issued an official Civilian Government Employee Identification Badge. This includes immediate notification to the security office if your badge is lost or stolen.

All CMS Government issued identification, access cards, and parking permits must be returned to the ASG, Security and Safety Staff prior to the last day of employment at CMS, or expiration of authorized access. Individuals who do not return their Government issued Access card(s) within 48 hours following separation from CMS (regardless of contract date), will be permanently barred from the CMS complex and are subject to fines and penalties associated with theft of Government property under Federal Property Management Regulations, Title 41, Code of Federal Regulations, Preservation of Property Subpart 101-20.303.

Signature Date

Form CMS-730A (11/03) (ALL OTHER EDITIONS OBSOLETE) 2

REQUIRED APPROVALS

OIS / OOM Use Only

CARD NO.______________________________

OIS/TMG Physical Security Officer for Computer Facilities ____________________________________________

OOM/SSS Personnel Security Representative _____________________________________________________

Background Investigation Conducted ❏ Level 1 ❏ Level 5 ❏ Level 6

OOM/SSS Badging Personnel Initials ____________________________________________________________

INSTRUCTIONS: REQUEST FOR PHYSICAL ACCESS TO CMS FACILITIES

Prior to submitting form CMS-730A to the Security and Safety Staff, ASG, OOM (SLL-11-05), ALL required signatures MUST be obtained, otherwise this form will not be processed. NO EXCEPTIONS.

All forms, requiring electronic access to any CMS facility, must be submitted to the OIS/TMG Physical Security Officer for Computer Facilities ( m/s N1-19-18 — desk N1-24-17).

NOTE: Each time a CMS-730A form is revised it supersedes the previous form. You must enter all accesses needed.

Purpose of this Form

Information from this form is used primarily as the basis to grant access to any CMS facility and secured areas.

Part I – Applicant Information (To be completed by Applicant – Required):

SSN – Provide SSN Phone Number – Provide the phone number where you can be contacted during duty hours.

Applicant’s Name – Print full name clearly.

Company Name – Print company name (clearly – if subcontractor, please include parent company name).

Part II – Reason For Application (Required):

Check the reason for this application.

Part III – Type of Badge (required for initial issuance only):

Enter type of badge needed.

PART IV – Electronic Access (Required for access to secured areas):

Be sure to select a personal 4-digit pin number in the space provided.

Electronic Access areas (secured areas) should only be requested if you need them to perform your duties. A thorough justification is mandatory for anyone requesting electronic access (PART V).

PART V – Electronic Access Justification (Required for all accesses checked in PART IV)

A thorough justification is required for all accesses requested in PART IV. Just stating access is needed will not be accepted as a justification.

PART VI – Property Pass Information:

Provide a description and serial number for each item you are bringing into the building.

PART VII – Background Investigation:

Provide a level of investigation that corresponds to your job duties/responsibilities (position sensitivity determination).

PART VIII – Authorizations: (To be completed by Project Officer)

Project Officer’s Name – Print name clearly.

Project Officer’s Signature – Sign name and date. (see Note)

Authorizations: (To be completed by Contract Officer)

Contract Officer’s Name – Print name clearly.

Contract Officer’s Signature – Sign name and date.

Contract Number – Provide the contract number of applicant’s company.

Contract Expiration Date – Provide the contract expiration date of applicant’s company.

You are responsible for reading the Privacy Act Statement on Page 2 of the Request for Physical Access to CMS Facilities Form. Your signature is required, as indicated under the Privacy Act Statement, to acknowledge you have read these requirements.