Security_Requirements_Attachments_Portfolio.pdf

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Note: Knowingly and willfully providing false information on this form may subject the requester to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. 552a(i)(3). Revised: 11/21/13

Plum Island Animal Disease Center Visitor Application

I request permission for the following person(s) to visit Plum Island on: 03/06/14 through 03/07/14

Weekend Access Requested Non-Business Hours Access Requested

* I request that an extended PIADC pass be issued for the dates listed above. (Note: Min 5 days but not to exceed one year) *

Name

US

Citizen

Country of

Citizenship Country of Origin Arrival Time

Departure

Time

NY/

CT

Yes

Yes

Purpose of Visit: WWTDS Preproposal Conference

Company Name: Phone Number: ( ) -

Address:

The visitor(s) will be in the following areas: (Please check all that apply)

Zone 1

Bldg 100 Admin Orient Point PI Harbor Construction Site Security Control Center*

Bldg 100 Vaccine Bank* Server Room* Power Plant* Bldg 100 BSL2 * Bio-compound (inside fence)*

Zone 2

Bldg 101 Common* Bldg 101 Machine Space* Bldg 102* IDF/MDF*

Zone 3

Bldg 101 Labs C/D* Bldg 101 Lab Modules* Bldg 101 APHIS* Bldg 101 ARS*

Zone 4

Bldg 101 Repository* Bldg 101 ARU/Necropsy* Bldg 101 Animal Rooms Forensic Laboratory

Other: Working with unknowns or zoonotic agents (requires serum banking)

*Criminal Background Check Required. Complete NCIC Information Form and follow directions on the form.

Vehicle Required: No (Contact ext. 3300 for ferry reservations)

Camera Required (Camera phones included): Laptop Equipment Required: No Video Equipment Required No

Laptop/Electronic Equipment Required: (contact IT department) No Network Connection Required No Government Furnished No Purpose:

I accept full responsibility for informing the above listed visitor(s) of the rules, regulations, and restrictions associated with their visit(s) to

PIADC. I will provide escort for the visitor(s) during the visit(s).

Sponsor Name: Ext:

Sponsor Signature: Date:

For Security Use Only:

Zone 1 Orientation Zone 2 Orientation Zone 3 Orientation

Serum Banking Required Other ____________________

NCIC Background Check Required Yes Completed Date No Waived________________________

NCIC Approved:

PIADC Security Officer _____________________________ Date _____________

Reviewed and Approved by:

PIADC Security Analyst _____________________________ Date _____________

*This application must be submitted 24 business hours prior to arrival of visitor(s) and ALL fields must be completed. If NCIC check is required, fill out the NCIC form and follow instructions. Submit 5 working days prior to arrival.

Last, First:

Country:

Country of Origin:

Time:

Company Name:

Number and Street, City, State, Zip:

000:

0000:

Yes/No: [ ]

NY/CT: [ ]

Name of Attendee Gender Shoe Size Tyvek Suit Size

PIADC Preproposal Conference Attendee Information Form

Point of Contact (POC):

Company Name:

POC Phone Number:

POC Email:

Company Name:

Email Address:

Phone:

Last, First:

M or F: [ ]

Size: [ ]

Suit: [ ]

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

Protected Critical Infrastructure Information (PCII)

DHS Form 11000-6 (08-04)

Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned by, produced by, or in the possession of the United States Government.

(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer's willingness to comply with the standards for protection by placing his or her initials in front of the applicable category or categories.)

Initials:

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law 107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCII Program Manager or the PCII Program Manager's designee.

Sensitive Security Information (SSI)Initials:

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, "Protection of Sensitive Security Information," "Policies and Procedures for Safeguarding and Control of SSI," as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

Other Sensitive but Unclassified (SBU)Initials:

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information, not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Section 552a of Title 5, as amended, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement Sensitive (LES);

Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the guidance provided to me relative to the specific category of information.

I understand and agree to the following terms and conditions of my access to the information indicated above:

3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/or directives applicable to the specific categories of information to which I am granted access. I understand that the United States Government may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination, handling and safeguarding information under this Agreement.

I, , an individual official, employee, consultant, or subcontractor of or to (the Authorized Entity), intending to be legally bound, hereby consent to the terms in this

1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

2. By being granted conditional access to the information indicated above, the United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement and the laws, regulations, and directives applicable to the specific categories of information to which I am granted access.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other types of information, to include classified national security information.

4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority or authorization. Should situations arise that warrant the disclosure or release of such information I will do so only under approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally relayed to me by the proper authority.

5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever that is in my possession.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager's designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CII Act, as amended.

(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program Manager or the PCII Program Manager's designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be kept to the extent possible when reporting security violations.

9. (a) With respect to SSI and SBU, I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information not consistent with the terms of this Agreement.

(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCII not consistent with the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the United States Government or the Authorized Entity. By granting me conditional access to information in this context, the United States Government and, with respect to PCII, the Authorized Entity, may seek any remedy available to it to enforce this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

DHS Form 11000-6 (08-04) Page 2

11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by this Agreement apply during the time that I am granted conditional access, and at all times thereafter.

12. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be unenforceable, all other provisions shall remain in full force and effect.

13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure Agreement which I have executed or may execute with the United States Government or any of its departments or agencies.

14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by Executive Order No. 12958, as amended; Section 7211 of Title 5, United States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2302(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 USC 421 et seq.) (governing disclosures that could expose confidential Government agents); and the statutes which protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798, and 952 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 USC 783(b)). The definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive Order and listed statutes are incorporated into this agreement and are controlling.

15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.

16. I represent and warrant that I have the authority to enter into this Agreement.

17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I may read them at this time, if I so choose.

DHS Form 11000-6 (08-04)

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

Acknowledgement Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

I make this Agreement in good faith, without mental reservation or purpose of evasion.

Signature:

Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

Signature:

WITNESS:

This form is not subject to the requirements of P.L. 104-13, "Paperwork Reduction Act of 1995" 44 USC, Chapter 35.

Date:

Date:

DHS- 11000- 14

PAM WASHINGTON

IDENTIFICATION ACCESS CONTROL CARD REQUEST DOCUMENT

D:20050825155718- 04'00'

D:20050825155718- 04'00'

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

NON DISCLOSURE AGREEMENT

Protected Critical Infrastructure Information (PCII)

Protected Critical Infrastructure Information (PCI I)

DHS Form 11000-6 (08-04)

D H S Form 1 1 0 0 0-6 (08-04)

Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned by, produced by, or in the possession of the United States Government.

(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer's willingness to comply with the standards for protection by placing his or her initials in front of the applicable category or categories.)

Initials:

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law 107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCII Program Manager or the PCII Program Manager's designee.

I attest that I am familiar with, and I will comply with all requirements of the P C I I program set out in the Critical Infrastructure Information Act of 2002 (C I I Act) (Title 2, Subtitle B, of the Homeland Security Act of 2002, Public Law 1 0 7-2 9 6, 1 9 6 Statute 2 1 3 5, 6 U S C 1 0 1 et sequens.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCI I Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCI I Program Manager or the PCI I Program Manager's designee.

Sensitive Security Information (SSI)

Sensitive Security Information (SS I)

Initials:

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, "Protection of Sensitive Security Information," "Policies and Procedures for Safeguarding and Control of SSI," as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SS I information as cited in this Agreement and in accordance with 49 C F R Part 1 5 2 0, "Protection of Sensitive Security Information," "Policies and Procedures for Safeguarding and Control of SS I," as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

Other Sensitive but Unclassified (SBU)

Other Sensitive but Unclassified (SB U)

Initials:

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information, not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Section 552a of Title 5, as amended, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement Sensitive (LES); Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

As used in this Agreement, sensitive but unclassified information is an over arching term that covers any information, not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Section 5 5 2. A. of Title 5, as amended, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This includes information categorized by DHS or other government agencies as: For Official Use Only (F O U O); Official Use Only (O U O); Sensitive Homeland Security Information (SHS I); Limited Official Use (L O U); Law Enforcement Sensitive (L E S); Safeguarding Information (SG I); Unclassified Controlled Nuclear Information (UCN I); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the guidance provided to me relative to the specific category of information.

I understand and agree to the following terms and conditions of my access to the information indicated above:

3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/or directives applicable to the specific categories of information to which I am granted access. I understand that the United States Government may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination, handling and safeguarding information under this Agreement.

I, , an individual official, employee, consultant, or subcontractor of or to

(the Authorized Entity), intending to be legally bound, hereby consent to the terms in this

1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

2. By being granted conditional access to the information indicated above, the United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement and the laws, regulations, and directives applicable to the specific categories of information to which I am granted access.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other types of information, to include classified national security information.

4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority or authorization. Should situations arise that warrant the disclosure or release of such information I will do so only under approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally relayed to me by the proper authority.

5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever that is in my possession.

5. (A. ) For PC I I - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PC I I Program, whichever occurs first, I will surrender promptly to the PCI I Program Manager or his designee, or to the appropriate PCI I officer, PCI I of any type whatsoever that is in my possession.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager's designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CII Act, as amended.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCI I Program, I will not request, obtain, maintain, or use PCI I unless the PCI I Program Manager or Program Manager's designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CI I Act, as amended.

(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

(b) For SS I and SB U - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program Manager or the PCII Program Manager's designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SS I or SB U, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCI I, unless such alteration or removal is authorized by the PCI I Program Manager or the PCI I Program Manager's designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be kept to the extent possible when reporting security violations.

9. (a) With respect to SSI and SBU, I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information not consistent with the terms of this Agreement.

9. (A. ) With respect to SS I and SB U, I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information not consistent with the terms of this Agreement.

(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCII not consistent with the terms of this Agreement.

(b) With respect to PCI I I hereby assign to the entity owning the PCI I and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCI I not consistent with the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the United States Government or the Authorized Entity. By granting me conditional access to information in this context, the United States Government and, with respect to PCII, the Authorized Entity, may seek any remedy available to it to enforce this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the United States Government or the Authorized Entity. By granting me conditional access to information in this context, the United States Government and, with respect to PCI I, the Authorized Entity, may seek any remedy available to it to enforce this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

DHS Form 11000-6 (08-04)

DHS Form 1 1 0 0 0-6 (08-04)

11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by this Agreement apply during the time that I am granted conditional access, and at all times thereafter.

12. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be unenforceable, all other provisions shall remain in full force and effect.

13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure Agreement which I have executed or may execute with the United States Government or any of its departments or agencies.

14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by Executive Order No. 12958, as amended; Section 7211 of Title 5, United States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2302(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 USC 421 et seq.) (governing disclosures that could expose confidential Government agents); and the statutes which protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798, and 952 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 USC 783(b)). The definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive Order and listed statutes are incorporated into this agreement and are controlling.

14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by Executive Order Number 1 2 9 5 8, as amended; Section 7 2 1 1 of Title 5, United States Code (governing disclosures to Congress); Section 1 0 3 4 of Title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2 3 0 2(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 U S C 421 et sequens) (governing disclosures that could expose confidential Government agents); and the statutes which protect against disclosure that may compromise the national security, including Sections 6 4 1, 7 9 3, 7 9 4, 7 9 8, and 9 5 2 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 U S C 7 8 3(b)). The definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive Order and listed statutes are incorporated into this agreement and are controlling.

15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.

16. I represent and warrant that I have the authority to enter into this Agreement.

17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I may read them at this time, if I so choose.

DHS Form 11000-6 (08-04)

DHS Form 1 1 0 0 0-6 (08-04)

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

NON DISCLOSURE AGREEMENT

Acknowledgement

Typed/Printed Name:

Government/Department/Agency/Business Address

Telephone Number:

I make this Agreement in good faith, without mental reservation or purpose of evasion.

Signature:

Typed/Printed Name:

Government/Department/Agency/Business Address

Telephone Number:

Signature:

WITNESS:

This form is not subject to the requirements of P.L. 104-13, "Paperwork Reduction Act of 1995" 44 USC, Chapter 35.

This form is not subject to the requirements of P L 1 0 4-13, "Paperwork Reduction Act of 1995" 44 U S C, Chapter 35.

Date:

Date:

Name1:

AuthorizedEntity:

Initials1:

Initials2:

Initials3:

Name2:

Address:

Signature:

WitnessName:

WitnessAddress:

WitnessSignature:

WitnessPhone:

Telephone:

Signature Date. Enter 2 digit month, 2 digit day and 4 digit year.:

Signature Date. Enter 2 digit month, 2 digit day and 4 digit year.:

Plum Island Animal Disease Center United States Department of Homeland Security

Science and Technology Directorate

Security Office

P.O. Box 848 • Greenport, NY 11944-0848 Voice: (631) 323-3259 • Fax: (631) 323-3335

FOR OFFICIAL USE ONLY

CAMERA PASS

In accordance with the PIADC Security Plan – use of video, photo or digital cameras on PIADC are restricted without prior approval from the DHS Security Manager or designated alternate.

Through your signature acknowledging this policy and agreement to abide by the below limitations, you are granted permission to possess and use video, photo and / digital photography on Plum Island property.

Areas Not To Be Photographed

Security Officers

Security Stationary and Vehicle Posts and their locations

Security Control Center (Inside or Outside)

Lab Turnstile Area

Locations of Cameras, Door Controls or any features of the PIADC Security System

Firehouse

Identification Badges (Close-ups)

Server Room and Location

Vessel Cockpit and Engine Compartments

Harbor

I understand my responsibilities in this area and agree to comply. I also understand that any video or photographic images taken of Plum Island, it’s facilities, personnel and equipment are subject to review by the DHS Security Manager or Designated Alternate upon request.

LAPTOP USE

For the use of a personal laptop connecting to the PIADC network all visitors must have:

Written request from sponsor submitted to PIADC IT and Security

Current virus protection software with updates installed

All applicable operating systems with updates and patches installed

No peer to peer software installed (Ex: Limewire, WSFTP, etc)

All laptops are subject to inspection by the Plum Island IT staff at any time. The use of laptops may be revoked at any time.

(Print Name) (Company/Agency)

(Signature) (Date)

Completed forms are to be forwarded to the Security Manager’s Office.

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For Official Use Only

This document contains sensitive information exempt from mandatory disclosure under the Freedom of Information Act, 5 U.S.C 552(b) (2).

Do not release without prior approval by the Department of Homeland Security.

Rev. September 2013

Plum Island Animal Disease Center

National Crime Information Center (NCIC) Form

For all NCIC forms, allow 5 working days for processing prior to visitor arrival

Full Name

US Citizen

Country of Origin

Place of Residence

Date of Birth

Social Security Number

Telephone Number

Gender

TYPE ONLY in the table below (handwritten forms will NOT be accepted)

Please e-mail this document to PlumIslandSecurity@hq.dhs.gov

For your personal security, please DO NOT send you personal identifiable information (the information contained within this document) to any other number or e-mail address.

For questions or concerns, please contact:

Security Specialist Jerry Aylward: Jerry.Aylward@hq.dhs.gov or (631)-323-3390

Security Manager Jim Palmieri: Jim.Palmieri@hq.dhs.gov or (631)-323-3259

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