Att_(4)_DD-254.pdf

CLASSIFICATION (When filled in): Unclassified NRL SER: 027-19

DEPARTMENT OF DEFENSE 0MB No. 0704-0567

CONTRACT SECURITY CLASSIFICATION SPECIFICATION 0MB approval expires:

(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.) October 31, 2020

The public reporting burden for this collection of information, 0704-0567. is estimated to average 70 minutes per response, ind uding the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mi l. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of infom,ation if it does not display a currently valid 0MB control number.

RETURN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.

1. CLEARANCE AND SAFEGUARDING

a. LEVEL OF FACILITY SECURITY CLEARANCE (FCL) REQUIRED b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/ (See Instructions) MATERIAL REQUIRED AT CONTRACTOR FACILITY

Secret Secret

2. THIS SPECIFICATION IS FOR: (X and complete as applicable.} 3. THIS SPECIFICATION IS: (X and complete as applicable.}

• a. PRIME CONTRACT NUMBER (See instructions.)

~ ORIGINAL (Complete date in all cases.)

DA TE (YYYYMMDD)

a.

20 190326

• b. SUBCONTRACT NUMBER b. REVISED (Supersedes all previous specifications.)

• REVISION NO. DATE (YYYYMMDD)

c. SOLICITATION OR OTHER NUMBER DUE DA TE (YYYYMMDD)

~ N00 173-19 R-LN04 • c. FINAL (Complete Item 5 in all cases.) DA TE (YYYYMMDD)

4. IS THIS A FOLLOW-ON CONTRACT? !ZI No D Yes If yes, complete the following:

Classified material received or generated under (Preceding Contract Number) is transferred to this follow-on contract

5. IS THIS A FINAL DD FORM 254? !ZI No D Yes If yes, complete the following:

In response to the contractor's request dated , retention of the classified material is authorized for the period of:

6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)

a. NAME, ADDRESS, AND ZIP CODE b. CAGE CODE c, COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

FOR RFP PURPOSES ONLY; NOT V AUD FOR NIA

ACTUAL CONTRACT AW ARD NIA

7. SUBCONTRACTOR(S) (Click button if you choose to add or list the subcontractors

- but will still require a separate DD Form 254 issued by a prime contractor to each subcontractor)

a. NAME, ADDRESS, AND ZIP CODE b. CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

NIA NIA

NIA

8. ACTUAL PERFORMANCE (Click button to add more locations.)

a. LOCATION(S) (For actual performance, see instructions.) b. CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO) (If applicable, (Name, Address, ZIP Code, Telephone required; Email Address optional)

SEE BLOCK 13

see Instructions.}

NIA

NIA

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

R&D SUPPORT FOR NA VY TECHNOLOGY CENTER SAFETY AND SUR VIV ABILITY

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): Unclassified

AEM LiveCycle Designer

Solicitation: N00173-19-R-LN04 Attachment (4)

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)

0 a. COMMUNICATIONS SECURITY (COMSEC) INFORMATION

0 b. RESTRICTED DATA

• c. CRITICAL NUCLEAR WEAPON DESIGN INFORMATION (CNWDI) (If CNWDI applies, RESTRICTED DA TA must also be marked.)

0 d. FORMERLY RESTRICTED DATA

e. NATIONAL INTELLIGENCE INFORMATION:

D (1) Sensitive Compartmented Information (SCI)

IZJ (2) Non-SCI

0 f. SPECIAL ACCESS PROGRAM (~AP) INFORMATION

• g. NORTH ATLANTIC TREATY ORGANIZATION

(NATO) INFORMATION

0 h. FOREIGN GOVERMENT INFORMATION

• i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

IZJ j. CONTROLLED UNCLASSIFIED INFORMATION (CUI) (See instructions.)

IZ] k. OTHER (Specify) (See instructions.)

ACCESS TO SECRET GOVERNMENT AlS, AS

APPROVED

11 . IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 13 or 14 as set forth in the instructions.)

a. HAVE ACCESS TO CLASSIFIED INFORMATION ONLY AT

ANOTHER CONTRACTOR'S FACILITY OR A GOVERNMENT

0 ACTIVITY

(Applicable only if there is no access or storage required at contractor facility.

See instructions.)

0 b. RECEIVE AND STORE CLASSIFIED DOCUMENTS ONLY lvl c. RECEIVE, STORE, AND GENERATE CLASSIFIED ic,J INFORMATION OR MATERIAL

IZJ d. FABRICATE, MODIFY, OR STORE CLASSIFIED HARDWARE

0 e. PERFORM SERVICES ONLY

f. HAVE ACCESS TO U.S. CLASSIFIED INFORMATION OUTSIDE

0 THE U.S.,PUERTO RICO, U.S. POSSESSIONS AND TRUST

TERRITORIES

12. PUBLIC RELEASE

g. BE AUTHORIZED TO USE THE SERVICES OF DEFENSE

0 TECHNICAL INFORMATION CENTER (DTIC) OR OTHER

SECONDARY DISTRIBUTION CENTER

0 h. REQUIRE A COMSEC ACCOUNT

0 i. HAVE A TEMPEST REQUIREMENT

IXJ j. HAVE OPERATIONS SECURITY (OPSEC) REQUIREMENTS

0 k. BE AUTHORIZED TO USE DEFENSE COURIER SERVICE

I. RECEIVE, STORE, OR GENERATE CONTROLLED UNCLASSIFIED

IZI INFORMATION (CUI).

(DoD Components: refer to DoDM 5200. 01, Volume 4 only for specific CUI protection requirements. Non-DoD Components: see instructions.)

[] m. OTHER (Specify) (See instructions.)

Any information (classified or unclassified) pertaining to this contract shall not be released for public dissemination except as provided by the National Industrial Security Program Operating Manual (NISPOM) or unless it has been approved for public release by appropriate U.S. Government authority.

Proposed public releases shall be submitted for review and approval prior to release to the appropriate government approval authority identified here with at least office and phone contact information and if available, an e-mail address. (See instructions)

0 DIRECT IZ] THROUGH (Specify below)

13. SECURITY GUIDANCE

Public Release Authority:

Commanding Officer, Naval Research Laboratory, Washington DC 20275-5320, John Farley, Code 6186

The security classification guidance for classified information needed for this effort is identified below. If any difficulty is encountered in applying this guidance or if any other contributing factor indicates a need for changes in this guidance, the contractor is authorized and encouraged to provide recommended changes; to challenge the guidance or the classification assigned to any information or material furnished or generated under this contract;

and to submit any questions for interpretation of this guidance to the official identified below. Pending final decision, the information involved shall be handled and protected at the highest level of classification assigned or recommended.

(Fill in as appropriate for the classified effort. Attach, or forward under separate correspondence, any documents/guides/extracts referenced herein. The field will expand as text is added. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. Also allows for up to 6 internal reviewers to digitally sign. See instructions for additional guidance or use of the fillable PDF.)

1. Contractor personnel assigned to this contract, on or off site, must possess a favorably adjudicated DoD Tier 3 investigation and a final DoD granted Secret personnel security clearance. The number of Secret clearances requested from DSS is anticipated not to exceed 6.

2. Contractor will be required to receive, generate, or have custody of SECRET material at the contractor's facility.

3. Foreign Nationals are not authorized to work on this contract.

4 . CUI, such as Proprietary, Privacy Act or FOUO, etc. information associated with this contract, must be handled/controlled IA W DoD

5200.0 l Vol. 4.

5. Need-to-know certifications for visit requests to other U.S. Government/DoD contractor facilities, or for obtaining documentation/ information, will be processed through the contractor FSO. A visit request is required for all personnel assigned to work on this contract.

Visit requests must include full name, SSN, contract number and should also state if Government furnished computer equipment will be required.

6 . The prime contractor will forward a copy of all proposed subcontracts and task orders to the COR named in paragraph 8, related to this contract, regardless of classification, for review, approval and coordination with the officials named in paragraph 8. All subcontracts must be approved in writing, by the officials named in para 8, prior to the start of work.

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): Unclassified

AEM LiveCycle Designer

7. All contractors (mcludmg subcontractors) 1dent1hed m the Statement or Work shall supplement the1r current secunty practices by requiring any personnel involved in executing the contract to complete. Government-sponsored and administered Operations Security (OPSEC) training, OPSE-1301 and any OPSEC guidance that may pertain to the project.

8. The NRL COR for this contract is John Farley, NRL Code 6186, (202) 404-8459. The NRL security point of contact for this contract is the official named in 16d.

ACTUAL PERFORMANCE LOCATIONS:

NAVAL RESEARCH LABORATORY - CBD

5813 BAYSIDE ROAD

CHESAPEAKE BEACH, MD 20732

NAVAL SEA SYSTEMS COMMAND

1333 ISAAC HULL A VENUE

WASHJNGTON NAVY YARD

WASHINGTON, D.C. 20376

NAVAL STATION NORFOLK

1530 GILBERT STREET, SUITE 2000

NORFOLK, VA 23511

USNB- SAN DIEGO

3455 SENN STREET

SAN DIEGO, CA 92136

NAVAL AJR WEAPONS STATION - CHINA LAKE

l ADMINISTRA TTVE CIRCLE

RIDGECREST, CA 93555

List of Attachments (All Files Must be Attached Prior to Signing , i.e. , for any digital signature on the form)

NAME & TITLE OF REVIEWING OFFICIAL

14. ADDITIONAL SECURITY REQUIREMENTS

Requirements , in addition to NISPOM requirements for classified information, are established for this contract.

SIGNATURE

D No IZl Yes If Yes, identify the pertinent contractual clauses in the contract document ftself, or provide an appropriate statement which identifies the additional requirements. Provide a copy of the requirements to the CSO. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace keY, then click out of the text field for it to shrink after the text has been deleted.

(See instructions for additional guidance or use of the fillable PDF.)

SEE BLOCK 13, PARAGRAPH 7.

15. INSPECTIONS

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): Unclassified

AEM LiveCycle Designer

Elements of this contract are outside the inspection responsibility of the CSO.

Iv! No D y If Yes, explain and identify specific areas and government activity responsible for inspections. The field will expand as text is added or you can also use item ~ es 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted.

(See instructions for additional guidance or use of the fillable PDF.)

16. GOVERNMENT CONTRACTING ACTIVITY (GCA) AND POINT OF CONTACT (POC)

a. GCA NAME c. ADDRESS (Include ZIP Code) d. POC NAME

JAMES D. MILLARD

NAVAL RESEARCH LABORATORY

b. ACTIVITY ADDRESS CODE (AAC) OF THE CONTRACTING OFFICE (See Instructions)

4555 OVERLOOK A VE. SW.

WASHINGTON, D.C. 20375-5320

e. POC TELEPHONE (Include Area Code)

+ 1 (202) 767-2576

N00173

17. CERTIFICATION AND SIGNATURES

f. EMAIL ADDRESS (See Instructions) dave.millard@nrl.navy.mil

Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. Upon digitally signing Item 17h, no changes can be made as the form will be locked.

a. TYPED NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) d. AAC OF THE CONTRACTING OFFICE h. SIGNATURE (See Instructions) (See Instructions)

MILLARD, JAMES, D. N00173

b. TITLE e. CAGE CODE OF THE PRIME CONTRACTOR

BRANCH HEAD, INFORMATION SECURITY

c. ADDRESS (Include ZIP Code)

4555 OVERLOOK AVE. SW.

WASHINGTON, D.C. 20375-5320

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

IZ] a. CONTRACTOR

0 b. SUBCONTRACTOR

Iv! c. COGNIZANT SECURITY OFFICE FOR PRIME AND

~ SUBCONTRACTOR

• d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY

ADMINISTRATION

IZJ e. ADMINISTRATIVE CONTRACTING OFFICER

(See Instructions.)

f. TELEPHONE (Include Area Code)

+ ] (202) 767-2576

g. EMAIL ADDRESS (See Instructions) dave.millard@nrl .navy.mil

i. DA TE SIGNED (See Instructions)

2 9 MAR Z019

1v1 f. OTHER AS NECESSARY (If more room is needed, continue in Item 13 or on ~ additional page if necessary.)

1231 , 6102,6186

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE. Page 4 of 4 AEM LiveCycle Oesigner

CLASSIFICATION (When filled in): Unclassified