Attachment_2_-_HSHQE3-13-R-00006_SOW_Exhibits_-_Sep_2013.pdf

October 2011

List of Exhibits

EXHIBIT SOW

REF.

TITLE

1 Post Exhibit 2 List of Required Forms

2A 5.3.2.1 Contractor Information Worksheet 2B 13.3.6 Inventory of Government Provided Equipment 2C 11.1.1 Key Personnel Resume 2D 5.1.2.6 Lautenberg Statement 2E 13.3.1 Receipt for Government Property 2F 9.22.3 Record of Time of Arrival and Departure from Building 2G 7.2.1.4 Non-Disclosure Agreement 2H 9.17.3 DHS Form 3155, Offense/Incident Report

2I

Exhibit 9E DHS Form 11000-14, Identification Access Control Card Request

2J

Exhibit 9E DHS Form 11000-27, Federal Emergency Response Official Designation Request

3A 7.2.1 Contractor’s Certification of Basic Training

3B

6.3.1 Contractor’s Certification of Initial and Transitional-Platform Firearms and Less-Than-Lethal Weapons Training

3C 6.3.1 Contractor’s Certification of Government-Provided Training 3D 6.3.1 Contractor’s Certification of Refresher Training 3E 6.3.1 Contractor’s Certification of Weapons Refresher Training 4 6.4 Required Training

4A 6.2 Contractor’s Training Schedule and Plan 4B 6.4.1.2 Contractor-Provided Basic Training

4C

6.6.2 Contractor-Provided Initial and Transitional-Platform Firearms and Less-Than-Lethal Weapons Training and Qualifications

4D

6.6.5 Contractor-Provided Annual Weapons Refresher

Training and Qualification

4E 6.4.1.3 Contractor-Provided Refresher Training 4F 6.7.2 Government-Provided Orientation Training 4G 6.7.3 Government-Provided Screener Training 4H 6.9.2.5 Specialized Training 5 7.2.1 Contractor and PSO Data Files 6 9.21 Post Tracking System Instructions 7 5.2 Medical Questionnaire/Physical Abilities Test Manual

8A 14.6 Contractor-Provided Uniform Items 8B 14.7 Contractor-Provided Supplementary Equipment 8C 14.4 Contractor-Provided Firearms and Ammunition 8D 14.5 Contractor-Provided Personal Protective Equipment

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 1 of 127

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EXHIBIT SOW

REF.

TITLE

8E 14.2 Contractor-Provided Communications Equipment 8F 14.3 Contractor-Provided Vehicles 9A 13 Government-Provided Uniform Items 9B 13 Government-Provided Supplementary Equipment 9C 13 Government-Provided Personal Protective Equipment 9D 13 Government-Provided Communications Equipment

9E

13 Government-Provided HSPD-12 Personal Identification Verification (PIV) Card

9F 13 Form I-9 List of Acceptable Documents

1.4.6 Federal Management Regulations Subpart C, Conduct on

Federal Property (41 CFR 102-74)

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 2 of 127

Building # Bldg. Name Building Address Post # Post Description Post Location Armed/ Unarmed

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

VA0694 JSIC (Joint Staff) 116B Lakeview Parkway Suffolk, VA 23432 1 Fixed Roving

Visitor Access and Control, CCTV & Alarm Monitoring

Armed 12 6:30 AM 6:30 PM M-F, No Holidays Secret/DHS 251 3012.00 Yes

2 Fixed/ Roving Alarm Response and Escort Armed 8 8:00 AM 4:00 PM M-F, No Holidays Secret/DHS 251 2008.00 Yes

VA0491 JWFC (J7) (Joint Staff)

116 Lakeview Parkway Suffolk, VA 23432 1 Fixed Visitor Access and

Control Armed 24 12:01 AM 11:59 PM Sun-M-F-Sat Secret/DHS 365 8760.00 Yes

1A Supervisor Visitor Access and Control Armed 24 8:00 AM 8:00 AM M-F, No Holidays Secret/DHS 251 6024.00 Yes

1B Supervisor Main Guard House Armed 8 8:00 AM 4:00 PM M-F, No Holidays Secret/DHS 251 2008.00 Yes

2 Fixed/ Roving Alarm and CCTV Monitoring Armed 24 12:01 AM 11:59 PM Sun-M-F-Sat Secret/DHS 365 8760.00 Yes

3 Fixed/ Roving Entry Control Point ID Armed 24 12:01 AM 11:59 PM Sun-M-F-Sat Secret/DHS 365 8760.00 Yes

4 Fixed/ Roving Screening, Roving Patrol and Escort Armed 11.5 6:30 AM 6:00 PM M-F Secret/DHS 251 2886.50 Yes

5 Fixed/ Roving Screening, Roving Patrol and Escort Armed 11.5 6:30 AM 6:00 PM M-F Secret/DHS 251 2886.50 Yes

6.1 Fixed/ Roving Entry Control

Point ID Armed 2 6:30 AM 8:30 AM M-F Secret/DHS 251 502.00 Yes

6.2 Fixed/ Roving Roving Patrol and

Escort Armed 9.5 8:30 AM 6:00 PM M-F Secret/DHS 251 2384.50 Yes

Exhibit 1 Post Exhibit

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 3 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

7 Fixed/ Roving Vehicle Screening Armed 10 6:00 AM 4:00 PM M-F Secret/DHS 251 2510.00 Yes

8 Fixed/ Roving Entry Control Point ID Armed 24 12:01 AM 11:59 PM Sun-M-F-Sat Secret/DHS 365 8760.00 Yes

9 Fixed/ Roving Vehicle Inspection and Delivery Gate

Operator Armed 10 6:00 AM 4:00 PM M-F, No Holidays Secret/DHS 251 2510.00 Yes

11 Fixed/ Roving Event Security and Parking Lot Safety Armed 12 6:30 AM 6:30 PM M-F, No Holidays Secret/DHS 251 3012.00 Yes

VA0613 JFL (J9) Joint Staff

115 Lakeview Parkway, Suffolk, VA 23432 1 Fixed Lobby Armed 10 7:00 AM 5:00 PM Sun-M-F-Sat includes H Secret/DHS 365 3650.00 Yes

2 Fixed/ Roving

Lobby, alarm monitoring, response, and escort officer)

Armed 10 7:00 AM 5:00 PM Sun-M-F-Sat includes H Secret/DHS 365 3650.00 Yes

VA0729 JTEC (Joint Staff) 115 Lakeview Parkway Suffolk, VA 23432 1 Fixed Lobby Armed 10 7:00 AM 5:00 PM Sun-M-F-Sat including Holidays Secret/DHS 365 3650.00 Yes

2 Fixed/Roving

Lobby, alarm monitoring, response, and escort officer

10 7:00 AM 5:00 PM Sun-M-F-Sat including Holidays Secret/DHS 365 3650.00 Yes

9901VA USDC-NOAA 439 West York Street Norfolk, VA 23510 1 Fixed/ Roving Main Gate Armed 24 12:00 AM 12:00 AM Sun-M-F-Sat DHS Suitability 365 8760.00 Yes

TAS TAS TAS Armed As req As req As req See Separate Schedule for Dates/Hours etc. DHS Suitability 3630.00 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 4 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

VA0481 US Coast Guard 1430-A Kristina Way Chesapeake, VA 23382 1 Fixed Lobby (Front Desk) Armed 24 6:00 AM 6:00 AM Sun-M-F-Sat DHS Suitability 365 8760.00 Yes

VA1608 Federal Building 200 Granby Street Norfolk, VA 23510 1 Fixed/ Roving Main Entrance Armed 24 12:00 AM 12:00 AM Sun-M-F-Sat DHS Suitability 365 8760.00 Yes

2 Fixed/ Roving Main Entrance Armed 10.25 7:15 AM 5:30 PM M-F, No Holidays DHS Suitability 251 2572.75 Yes

` 3 Fixed/ Roving Main Entrance Armed 10.25 7:15 AM 5:30 PM M-F, No Holidays DHS Suitability 251 2572.75 Yes

4 Fixed/ Roving Main Entrance Armed 6.5 8:00 AM 2:30 PM M-F, No Holidays DHS Suitability 251 1631.50 Yes

VA0551 FBI 150 Corporate Blvd Norfolk, VA 23502 1 Fixed/ Roving Front Gate Armed 24 12:00 AM 12:00 AM Sun-M-F-Sat DHS/Top Secret 365 8760.00 Yes

2 Fixed/ Roving Lobby Armed 10 8:00 AM 6:00 PM M-F, No Holidays DHS/Top Secret 251 2510.00 Yes

VA0794 CIS 5678 East Virginia Blvd., Norfolk, VA 23502 1 Fixed Magnetometer Armed 9 7:30 AM 4:30 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

2 Fixed X-Ray Armed 9 7:30 AM 4:30 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

3 Roving Roving Patrol Armed 11 6:30 AM 5:30 PM M-F, No Holidays DHS Suitability 251 2761.00 Yes

VA0469 US Coast Guard 1441 Crossways Blvd., Suite 101, Chesapeake, VA 23326

1 Roving inside facility Armed 12 6:00 PM 6:00 AM M-F, No Holidays DHS Suitability 251 3012.00 Yes

2 Roving inside facility Armed 24 6:00 AM 6:00 AM S, S, H DHS Suitability 114 2736.00 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 5 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

9902VA US Army COE 803 Front Street Norfolk, VA 23510 1 Fixed Guard House Armed 24 12:00 AM 12:00 AM Sun-M-F-Sat DHS Suitability 365 8760.00 Yes

2 Fixed/ Roving Lobby Desk Armed 12 6:00 AM 6:00 PM M-F, No Holidays DHS Suitability 251 3012.00 Yes

VA0087 Portsmouth Fed.

Bldg

431 Crawford Street Portsmouth, VA 23704 1 Fixed/ Roving Lobby Armed 24 12:00 AM 12:00 AM Sun-M-F-Sat DHS Suitability 365 8760.00 Yes

2 Fixed/ Roving Lobby Armed 12 6:00 AM 6:00 PM M-F, No Holidays 251 3012.00 Yes

VA0738 SSA-Norfolk 5850 Lake Herbert Drive, Norfolk, VA 23510 1 Fixed/ Roving Lobby Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0738 ODAR-Norfolk 5850 Lake Herbert Drive, Norfolk, VA 23510 1 Fixed/ Roving Lobby Armed 9 8:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

VA0738 VA Office of Disability

5850 Lake Herbert Drive, Norfolk, VA 23510 1 Fixed/ Roving Lobby Armed 8.75 8:15 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2196.25 Yes

VA0708 US Attorney's Office

721 Lake Front Commons 3rd Fl, Newport News, VA

23605 1 Fixed/Roving Lobby Armed 9 8:30 AM 5:30 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

VA0511 US Attorney's Office

101 West Main Street Norfolk, VA 23510 1 Fixed/ Roving Lobby Armed 9.5 8:30 AM 6:00 PM M-F, No Holidays DHS Suitability 251 2384.50 Yes

VA0591 TRADOC 720 Thimble Shoals Blvd Newport News, VA 23606 1 Fixed/ Roving Front Desk Armed 24 12:00 AM 12:00 AM Sun-M-F-Sat DHS Suitability 365 8760.00 Yes

9905VA ERDC/JTEF

7025 Harbour View Blvd, Suite 105, Suffolk VA 23435

1 Fixed/ Roving Lobby Armed 11 7:00 AM 6:00 PM M-F, No Holidays DHS Suitability 251 2761.00 Yes

VA0616 SSA-Accomac 82581 Center Parkway Accomac, VA 23301 1 Fixed/ Roving Lobby Armed 7.5 8:15 AM 3:45 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 6 of 127

DHS Suitability

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Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

VA0759 SSA-Hampton Executive Crossing West, 1521 Hardy Cash Drive, Hampton, VA 23666 1 Fixed/ Roving Lobby Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0644 SSA-Portsmouth 3305 Airline Blvd Portsmouth, VA 23701 1 Fixed/ Roving Lobby Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0635 SSA-Suffolk 502 Hill Point Blvd Suffolk, VA 23434 1 Fixed/ Roving Lobby Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0653 SSA-Newport News

11706 Jefferson Ave., Newport News, VA 23606 1 Fixed/ Roving Lobby Armed 8.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

2 Fixed Magnetometer Armed 7.5 8:15 AM 3:45 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

3 Fixed Magnetometer Armed 7.5 8:15 AM 3:45 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0631 SSA-VA Beach 2875 Sabre Street

Virginia Beach, VA 23452-

1 Fixed/ Roving Lobby Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0688 IRS 903 Gateway Blvd, Hampton, VA 1 Fixed/ Roving inside facility Armed 8.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

VA0088 Federal Building 400 North Eight Street Richmond, VA 23200 1 Combination Roving Patrol Armed 24 12:00 AM 12:00 AM 24/7 DHS Suitability 365 8760.00 Yes

2 Fixed Main Entrance Armed 10 7:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2510.00 Yes

3 Fixed Main Entrance Armed 10 7:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2510.00 Yes

4 Combination Loading Dock Armed 10 7:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2510.00 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 7 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

5 Fixed 7th Street Door -

Employee ID Inspection

Armed 4 6:00 AM 10:00 AM M-F, No Holidays DHS Suitability 251 1004.00 Yes

5 Roving Roving Patrol of Exterior Armed 2 10:00 AM 12:00 PM M-F, No Holidays DHS Suitability 251 502.00 Yes

VA0632 Federal Bureau of Inv.

1970 East Parham Road Richmond, VA 23198 1 Combination Main Gate Armed 24 12:00 AM 12:00AM 24/7 Top Secret/DHS 365 8760.00 Yes

2 Roving Lobby Armed 9 8:00 AM 5:00 PM M-F, No Holidays Top Secret/DHS 251 2259.00 Yes

VA0639 Virginia State Building

600 East Broad Street Richmond, VA 23190 1 Fixed 3rd Floor Armed 8.5 8:00 AM 4:30 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

VA0496 US Atty Office 600 East Main Street Richmond, VA 23190 1 Fixed 19th Floor Armed 9 8:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

VA0676 SSA-

Charlottesville

1470 Pantops Place, 1st Floor Charlottesville, VA

19902 1 Fixed Main Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0676 ODAR-

Charlottesville

1470 Pantops Place, 2nd Floor Charlottesville, VA

19902 1 Roving Reception 2nd

Floor Armed 8.5 8:00 AM 4:30 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

VA0693 SSA - Farmville 324 Commerce Road Farmville, VA 23901 1 Fixed SSA Reception Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA3001 SSA -

Fredericksburg

9915 Jefferson Davis Highway, Fredericksburg, VA 22407

1 Fixed Main Lobby Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0656 SSA-W. Cary 1834 W. Cary Street Richmond, VA 23190 1 Fixed SSA Reception Armed 9 7:00 AM 4:00 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 8 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

2 Combination SSA Reception Armed 8 9:15 AM 5:15 PM M-F, No Holidays DHS Suitability 251 2008.00 Yes

VA0731 SSA - Midlothian 13551 Waterford Place Midlothian, VA 22812 1 Fixed SSA Reception Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0696 SSA - Glen Allen 4212 Park Place Ct Suite B Glen Allen, VA 23060 1 Roving 1st floor Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0728 SSA - Petersburg JDL Bldg., 100 Popular Dr Petersburg, VA 23805 1 Combination Main Lobby Armed 8.25 8:45 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2070.75 Yes

VA0793 SSA, Sandston 245 East Williamsburg Road, Sandston, VA

23150-1638 1 Fixed SSA Reception Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0661 ODAR-Wytestone Wytestone Plaza Bldg, 4th

Floor, 800 E. Main St.

Richmond, VA 23219

1 Fixed 4th floor Armed 8.5 8:00 AM 4:30 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

VA0665 SSA-Culpepper 1014 South Main St Culpepper, VA 19701 1 Roving 1st floor Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0819 FBI-Aquia Commerce Ct.

2721 Jefferson Davis Hwy Stafford, VA 22554 1 Combination Main Lobby Armed 8.75 8:15 AM 5:00 PM M-F, No Holidays Top Secret/DHS 251 2196.25 Yes

VA0764 DHS/ICE/ERO

9200 Arboretum

Parkway, Richmond, VA 23236-3489

1 Fixed Wanding/Screening Armed 8 8:00 AM 4:00 PM M-F, No Holidays DHS Suitability 251 2008.00 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 9 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

2 Fixed Access Control Armed 8 8:00 AM 4:00 PM M-F, No Holidays DHS Suitability 251 2008.00 Yes

VA0746 IRS 1320 Central Park Blvd., Fredericksburg, VA 1 Combination Inside Facility Armed 8.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251.00 2133.50 Yes

VA0712 IRS 401 E. Market Street, Charlottesville, VA 1 Combination Inside Facility Armed 8.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251.00 2133.50 Yes

VA0095 Poff Federal Bldg 210 Franklin Road, S.W., Roanoke, VA 24011 1 Roving Main Entrance Armed 24 12:00 AM 12:00 AM 24/7 DHS Suitability 365 8760.00 Yes

2 Fixed 2nd Floor Armed 12 6:00 AM 6:00 PM M-F, No Holidays DHS Suitability 251 3012.00 Yes

3 Fixed Loading Dock Armed 9 7:00 AM 4:00 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

VA0721 ODAR Roanoke 612 Jefferson Street, Roanoke, VA 1 Fixed 2nd Floor Armed 9 8:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

SSA-Roanoke 612 Jefferson Street, Roanoke, VA 2 Combination 1st floor Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

DDS, Roanoke 612 Jefferson Street, Roanoke, VA 3 Fixed Entrance Armed 9 8:00 AM 5:00 PM M-F, No Holidays DHS Suitability 251 2259.00 Yes

VA0705 US Atty Office 310 First Street S.W, Roanoke, VA 24011 1 Combination Main Entrance Armed 12 7:00 AM 7:00 PM M-F, No Holidays DHS Suitability 251 3012.00 Yes

VA0735 SSA-Bristol 2484 Lee Highway, Bristol, VA 24201 1 Combination Main Entrance Armed 8 8:45 AM 4:45 PM M-F, No Holidays DHS Suitability 251 2008.00 Yes

VA0604 SSA-Covington 1010 South Craig Avenue, Covington, VA 24426 1 Combination Main Entrance Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 10 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

VA0784 SSA, Danville 3295 US Highway 29, Danville VA 24540 1 Combination Main Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0795 SSA-Harrisonburg 351 N Mason Street, Harrisonburg, VA 22802 1 Combination Main Entrance Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0691 SSA-Martinsville 320 W. Commonwealth Blvd, Martinsville, VA

24112 1 Combination Main Entrance Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0539 SSA-South Boston 2049 Hamilton Blvd, South Boston, VA 24592 1 Combination Main Entrance Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0711 SSA-Lynchburg 7618 Timberlake Rd., Lynchburg, VA 24501 1 Combination Main Entrance Armed 7.75 8:45 AM 4:30 PM M-F, No Holidays DHS Suitability 251 1945.25 Yes

VA0610 SSA-Staunton Greenbrier Office Park, Bldg 2, 1600 N. Coalter St. Staunton, VA 24401

1 Combination Main Entrance Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0789 SSA-Wytheville 130 Withers Lane, Wytheville, VA 24382 1 Combination Main Entrance Armed 7.5 8:55 AM 4:25 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0520 SSA-Wise 253 Ridgeview Center Rd., S.W, Wise, VA 24293-

1 Combination Main Entrance Armed 7.5 8:45 AM 4:15 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0486 IRS 1600 N. Coalter Street, Staunton, VA 1 Combination Inside Facility Armed 8.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 11 of 127

Hrs Per Day Start Time End Time Performance Days Security Clearance Total Days Total Hrs Required

Relief?

Exhibit 1 Post Exhibit

VA0573 IRS 2426 Lee Highway Bristol, VA Combination Inside Facility Armed 7.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

1 11:30 AM 12:30 PM 1 hr Un-paid Break (M-F, No H or W)

VA0535 IRS 210 1st Street, Roanoke, VA Combination Inside Facility Armed 8.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251 2133.50 Yes

VA0593 IRS 3303 North Main Street, Danville, VA 1 Combination Inside Facility Armed 7.5 8:15 AM 4:45 PM M-F, No Holidays DHS Suitability 251 1882.50 Yes

VA0576 Dept. of Veteran's Affairs

Stone Print Plant Building, 116 N. Jefferson

Street, Roanoke, VA 1 Fixed X-Ray Armed 12 6:00 AM 6:00 PM M-F, No Holidays DHS Suitability 251 3012.00 Yes

2 Combination Wand Person Armed 12 6:00 AM 6:00 PM M-F, No Holidays DHS Suitability 251 3012.00 Yes

3 Combination Greeter Armed 12 6:00 AM 6:00 PM M-F, No Holidays DHS Suitability 251 3012.00 Yes

9931VA FBI Construction Site

609 Resource Row, Chesapeake, VA 23328 1 Combination Construction Site Armed 24 6:00 AM 6:00 AM Sun-M-F-Sat Top Secret/DHS

Suitability 365 8760.00 Yes

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 12 of 127

Exhibit 2 List of Required Forms

Form

SOW

Reference

Form Title

Location

5.3.2.1 Contractor Information Worksheet Exhibit 2A

5.3.2.1 e-Verify Confirmation Notice e-Qip

5.3.2.1 Foreign National Relatives or Associates

Statement e-Qip

13.3.6 Inventory of Government Provided

Equipment

Exhibit 2B

11.1.1 Key Personnel Resume Exhibit 2C

5.1.4

Lautenberg Amendment Statement e-Qip Exhibit 2D

5.2.2.1 Medical Questionnaire/Physical Abilities

Test Administrator’s Manual

Exhibit 7

13.3.1 Receipt for Government Property Exhibit 2E

9.2 Security Post Assignment Record

(Post Orders)

On Post

DD 254

5.4.1.1

Security Requirements Checklist Provided by Government

DD 441

5.4.1.5

Security Agreement Provided by

DHS 139

9.22.3 Record of Time of Arrival and Departure

from Building

Exhibit 2F

DHS

11000-6

7.2.1.4

Non-Disclosure Agreement

Exhibit 2G

11000-9

5.3.2.1

Disclosure and Authorization Pertaining to Consumer Reports pursuant to the Fair Credit Reporting Act

FD 258

5.3.2.1

Fingerprint Application Card Provided by

DHS 3155 9.17.1 Offense/Incident Report Exhibit 2H SF 85P 5.3.2.1 Questionnaire for Public Trust Positions e-Qip

SF 85PS

5.3.2.1 Supplemental Questionnaire for Selected

Positions

SF 86

5.4.3.1 Questionnaire for National Security

Positions

11000-14

Exhibit 9E

Identification Access Control Card Request

Exhibit 2I

11000-27

Exhibit 9E Federal Emergency Response Official

Exhibit 2J

OF-306 5.3.2.1 Declaration for Federal Employment Provided by Government

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 13 of 127

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Exhibit 2A Contractor Information Worksheet

Type Contractor PSO Non-PSO

Prefer Online (e-QIP)

(MBI / LBI / BI only) Routine Expedite (Extra Cost)

1. Contract Employee Information NAME: Last/Family First/Given Middle Suffix

Social Security

Date of Birth

MMDDYYYY

Place of Birth: City State Country

E-mail Address Phone # (Day) Phone # (Cell)

Position (Job) Title IT/System Admin Position?

Prior Investigation?

Yes No

Investigation Date Sex Male Female

U.S. Citizen Yes No

Aliens: Port of Entry City and State Date of Entry Alien Registration # Citizenship

2. Contract Information Company Name Company is

Prime Sub Contractor

If Sub, Name of Prime

Contract /Work Order / RWA # Contract Start Date

End Date

Has Option Years OR End Date TBD

Company Point of Contact (POC) Name

Phone # (Day) E-mail Address

3. Project/Work Location Information (Government site where contractor is working) Building Name GSA Building # Building Address

4. Type of Investigation Requested for: HSPD-12 PIV Card Credential Public Trust Positions (Suitability) Moderate Risk - (LBI / MBI) HIGH Risk - (BI)

National Industrial Security Clearance

CONFIDENTIAL (NACLC)

SECRET (NACLC) TOP SECRET

(SSBI)

5. Requesting Official (Sponsor) Information

Sponsor's Name

Title

Is COR/COTR

Yes

FPS Regional Office Number

E-mail Address Phone # (Day) Forms Reviewed Yes

Review Date

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 14 of 127

6. DHS Federal Protective Service Contract Suitability Adjudication (Staff use ONLY) Personnel Security Investigation:

OPM PIPS Inv

Inv #

Status

Date of INV e-QIP Invitation #

Date E-Mail Sent

Release Form

CER

Med Release

GSA 3665

FD 258

CS Case

FD 258 RAP

Just

Date Forms Received

SF85PReviewed

Scanned/TIF

Date Sent to OPM

Suitability Decision Preliminary Date

Favorable Unfavorable

Fi nal Date

Favorable Unfavorable

Notify Preliminary Decision eMail: COTR/ Requesting Official eMail: Subject eMail: Subject’s Company POC

Final Decision eMail: COTR/ Requesting Official eMail: Subject eMail: Subject’s Company POC

Comments/Notes:

Contractor Information Worksheet Instructions

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 DHS 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 and accurate

2. Return this form to your Supervisor/Contracting Officer for delivery to FPS Regional Field Contract Suitability Adjudication Office for “e- QIP” invite.

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

4. MAILING INSTRUCTIONS FOR FPS Staff:

If the contractor is a Non-Protective Security Officer (PSO) and performing contract administrative duties on the PSO contract at the federal government facilities, the background investigation package must be mailed to the respective FPS Regional Contract Suitability Adjudication Field Offices listed below:

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 15 of 127

Region

Regional CSA PoC

Phone #

FAX

Street Suite, Room

City

ST

Zip + 4

HQ

Evelyn Flores (202) 245-

(202) 245-

1900 Half St SW

Rm 5354

Washington

DC

20528

HQ

Sean Mihaly (202) 245-

1900 Half St SW

Rm 5351

ARRA

Terry Hudson (202) 245-

1900 Half St SW Rm 5350- S

Valerie DiMare (617) 565-

(617) 565-

10 Causeway St 935 Boston MA 02222-

George L. Ware (212) 264-

(212)264-

26 Federal Plaza

17-130

New York

NY 10278-

Lisa M. Leo (215) 521-

(215) 521-

701 Market St

4200 Philadelphia PA 19106-

Todd Ware (404) 893-

(404) 893-

180 Spring St, NW

525 Atlanta

GA 30303-

Doris Meaux (312) 353-

(312) 353-

230 S. Dearborn St.

Chicago

IL 60604-

6 Sara Reisenbichler

(816) 426-

(816) 426-

601 E 12TH ST

1712 Kansas City

MO 64106-

7 Contact COTR

"Mike" Prado

(303) 236-7813 x326

(303) 236-

W 6TH Ave & Kipling St

Lakewood

CO 80225-

May S. Joe (213) 894-

(213) 894-

300 N Los Angeles St.

2207 Los Angeles

CA 90012-

Janis Davis (253) 815-

(253) 815-

32125 - 32nd Ave S.

2nd Fl

Auburn

WA 98001-

11 Contact COTR

Type of Investigation Requirements- Contractor

Position Type

National

Position Sensitivity Levels Special & Critical Sensitive

Clearance Levels DHS Investigation Requirement

Top Secret / Top Secret-SCI SSBI – Single Scope Backgrnd Inv

Security Non-Critical Sensitive Secret / Confidential NACLC – National Agency Checks w/Law & Credit

High Risk N/A BI – Background Investigation Moderate Risk N/A MBI – Minimum Background Investigation

Public Trust Low Risk N/A NACI – National Agency Check w/Written Inquiries

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 16 of 127

Exhibit 2B Inventory of Government-Provided Equipment

Inventory of Government Provided Equipment

Item Brand Name Model Serial # Misc Issued To

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 17 of 127

Exhibit 2C Key Personnel Resume

Employee’s Name: SSN: - -

PROPOSED POSITION TITLE:

SUPERVISOR'S NAME:

CURRENT POSITION WITH THE CONTRACT FIRM:

TIME IN CURRENT POSITION: (Yrs. Mos.)

RESPONSIBLE FOR THE WORK OF: PERSONS

DESCRIPTION OF SCOPE OF CURRENT JOB: (Use attached sheet if necessary)

WORK EXPERIENCE: (Beginning with the most recent for the past 10 years.)

Dates (From – To)

Position or Title Company Name and Address

Reference and Phone Number

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 18 of 127

Employee’s Name: SSN: - -

EDUCATION SUMMARY:

Name and Address of Institution

Dates Attended

Diploma or Certificate

High School College Technical Trade Schools

PROVIDE A BRIEF STATEMENT OF WHY CONTRACTOR BELIEVES THAT THIS

INDIVIDUAL HAS THE QUALIFICATIONS FOR THIS CONTRACT.

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 19 of 127

Exhibit 2D Lautenberg Statement

Public Law 104-208 & Title 18 USC Sections 921, 922 and 925

1. Public Law 104-208 has amended Title 18, United States Code, Sections, 921, 922 and 925, making unlawful for any person convicted of a misdemeanor crime of domestic violence (spouse abuse, parent abuse, child abuse, etc.) to ship, transport, possess, or receive firearms or ammunition. Presently, there are no exceptions or time limits included in this law.

2. Therefore, anyone ever convicted of the subject crime(s) would be affected by its provisions. Since a person convicted of a misdemeanor crime of domestic violence can NOT possess a firearm or ammunition, such a person may NOT perform as an armed Contract employee.

3a. Have you ever been convicted of a misdemeanor crime of domestic violence, as defined by 18 U.S.C. §921(a)(33)?

YES NO

3b. If you answered YES, provide the following information with respect to each conviction:

a. Court/Jurisdiction:

b. Docket/Case Number:

c. Statute/Charge:

d. Date Sentenced:

3c. I certify that, to the best of my information and belief, all of the information provided by me here is true, correct, current, complete and made in good faith. I understand that false or fraudulent information provided herein may be grounds for adverse action, up to and including removal, and is also criminally punishable pursuant to Federal law, including 18 U.S.C. §1001.

Signature: Date Signed:

Name:

(Print your complete legal name)

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 20 of 127

Exhibit 2E Receipt for Government Property

Federal Protective Service

Government Property Hand Receipt TRANSFERRED FROM (AGENCY): TYPE OF TRANSFER Page of

Permanent

Transfer

Temporary

Loan

Date

Property Custodian

TRANSFERRED TO (COMPANY):

Telephone Number

Estimated return date if temporary:

Instructions or Remarks:

Item No.

(1)

Description (2)

Bar Code Number (3)

Serial Number (4)

Unit of Issue (5)

Original Cost (6)

Acceptance of Responsibility: I certify that I received the above listed Government Accountable Property, it is in my physical custody, and that the list includes all currently issued items. I am responsible for the proper use, care, and safeguarding of all Government Property in my possession or under my accountability and stewardship control. I will report any changes to this Hand Receipt within five (5) business days to the Property Custodian.

Issued by (print name): Received by (print name):

Date Signature and Title Date Signature and Title

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 21 of 127

Exhibit 2F Record of Time

Arrival and Departure from Facility

RECORD OF TIME OF ARRIVAL

AND DEPARTURE FROM

BUILDINGS (DURING SECURITY

HOURS)

BUILDING YEAR MONTH

DATE

PRINT NAME

(Last - First - Initial)

SIGNATURE

AGENCY

OR FIRM

ROOM

NUMBE

R

PURPOSE

OF VISIT

*SEE

FOOTNOTE

TIME OF

ARRIVA

L

DEPARTUR

E

*Federal Protective Service and Contract Administration personnel, when conducting an investigation, must place an "X" in this column.

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 22 of 127

Exhibit 2G Non-Disclosure Agreement

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE 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 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:

Protected Critical Infrastructure Information (PCII)

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 Law107-296, 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)

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)

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.

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 23 of 127

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

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.

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.

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.

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.

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 24 of 127

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.

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.

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 25 of 127

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

Acknowledgement

Typed/Printed Name: Telephone Number:

Government/Department/Agency/Business Address

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

Signature:

Date:

WITNESS:

Typed/Printed Name:

Telephone Number:

Government/Department/Agency/Business Address

Signature:

Date:

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

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 26 of 127

Exhibit 2H Offense/Incident Report

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 27 of 127

INSTRUCTIONS

1. TYPE. Enter an X to indicate if this is an original, continuation page, or a supplement to a report previously made.

2. CODE NO. (OFFENSE/INCIDENT CODE). *Enter 4-digit offense/incident code that corresponds to the offense/incident. In cases of vandalism, enter the offense/incident code number 1010 or 1020 and enter the word "vandalism" in Item 3, followed by the estimated dollar amount of damage. (Round off amount to nearest dollar; do not use decimal or cents.)

2a. SORT. In those incidents involving the use of Special Operations Response Teams (SORT), place an X in this block.

3. TYPE OF OFFENSE OR INCIDENT. Enter in words the type of offense or incident being reported.

4. CASE CONTROL NO. Enter 11-character alphabetical/ numerical case number which is obtained from the control center. The case control number is constructed as follows: first and second places designate the region; third place, the district; fourth place, the zone; fifth place thru ninth, the number of cases listed consecutively through tout the calendar year; 10th place, a letter designating the month, e.g., A=January, B=February, C=March, etc. The 11th place designates the calendar year. Only the last digit of the calendar year is entered. For example: in Region 8, District 2, Zone 5, the 4392 case of the year, occurring in FEBRUARY 1983, would be entered as 082504392B83.

5. BUILDING NO. Enter 8-character GSA building number. When building number does not apply, enter NA (not applicable) . (It is the responsibility of each region to provide these numbers to all officers.)

6. ADDRESS. Enter street, city, and State where offense/incident occurred.

7. AGENCY/BUREAU NAME. Enter agency/bureau name (i.e., Internal Revenue Service (IRS)).

8. AGENCY/BUREAU CODE. Enter 4-character agency/ bureau code in which offense/incident occurred.

(It is the responsibility of each region to provide these numbers to all officers.)

9. SPECIFIC LOCATION. Enter in words a brief description of location of offense/incident. Always begin with general area, then room area, and then specific location (e.g., 1st floor, office, desk). Refer to example in Item 10.

10. LOCATION CODE. *Enter alphabetical/numerical code. The first two places identify the general area or floor level where the incident occurred. The third and fourth places identify the room area; the fifth and sixth places provide the specific location of the incident. For example, if the offense/incident occurred on the first floor, in an office, from a desk code 010FDK would be entered for Item 10. (the last two places are used primarily in theft incidents. When use of the fifth and sixth places is inappropriate, enter NA (not applicable)).

11a and b. DATE/TIME OF OFFENSE/INCIDENT. Enter month, day, year and military time of offense/incident. Months must be entered in numerical order (i.e., January-01 through December-12). (If the date of the offense/incident is March 9, 1998, it would be recorded as 030998.) If exact date is unknown, but date last seen can be determined, enter that date. If neither of these dates is known, enter UNK (unknown).

12. DAY. Enter 2 letters for day of week on which the offense/incident occurred. Codes for days of the week are: SU, MO, TU, WE, TH, FR, SA, and UK (unknown).

13a and b. DATE/TIME REPORTED. Follow same instructions as in Item 11.

14. DAY. Follow same instructions as in Item 12.

1. JURISDICTION. Enter an X in the appropriate box.

2. NO. OF DEMONSTRATORS. Enter the estimated number of demonstrators.

3. NO. EVACUATED. Enter the estimated number of evacuees.

SOW Exhibits HSHQE3-R-13-00006, Amendment 5 Page 28 of 127

17a. TIME START. Enter the time when evacuation began (use military time).

17b. TIME END. Enter the time the evacuees returned to evacuated area (use military time).

18. PERSONS INVOLVED. (Suspect, Victim, Witness, Reporting Party). If there are more than two people involved, prepare an additional GSA Form 3155. Use the same case number and fill in only the appropriate blocks.

18a. ID (IDENTIFICATION) CODE. Enter appropriate codes of persons involved: SU-suspect;

VI-victim; WI-witness; RP-reporting party. If there is more than one person in same category, enter a numeric suffix as 1, 2, etc., (e.g., SU1, SU2, etc.).

18b. NAME AND ADDRESS. Enter name(s) and address(es) of person(s) identified. Record subject's full name. Show last name first, followed by first name, then middle initial. If subject doesn't have a middle initial, use NMI (no middle initial) to indicate this.

18c. AGE. Enter age if known; otherwise, enter UNK (unknown).

18d. SEX. Enter M-male or F-female.

18e. RACE. Enter appropriate code: A-Asian Pacific/Oriental; H-Hispanic, I-American Indian; B- Black; W-White; O-Other (explain in narrative), X-Unknown.

18e1. COUNTRY OF BIRTH. Enter Country Name if known.

18e2. NATIONALITY. Enter Nationality if known

18f. INJURY CODE. Enter appropriate code: O-none; 1-refused treatment; 2-first aid only; 3-hospitalized;

4-deceased.

18g. TELEPHONE. If known, enter area code(s) and number(s); otherwise, enter UNK (unknown).

19. VEHICLE. If more than one vehicle is involved, prepare an additional GSA Form 3155. Use the same control number and fill in only the appropriate blocks.

19a. STATUS. Check the appropriate box(es).

19b. YEAR. Enter model year of vehicle.

19c. MAKE. Enter make of vehicle.

19d. MODEL. Enter model of…