PSNS 5512.pdf

Controlled by: PSNS & IMF Controlled by: PSNS & IMF Security Division (Code 1120) CUI Category: PRVCY Limited Dissemination Control: FEDCON POC: James Lloyd (360) 476-8867

CUI (when filled in)

CUI (when filled in)

Ref: PSNS&IMFINST 5530.1

VISITOR ACCESS AND BADGE REQUEST

A trusted agent must submit this form 7 days before visiting Puget Sound Naval Shipyard and Intermediate Maintenance Facility (PSNS & IMF) via Microsoft Teams or encrypted e-mail to james.l.lloyd.civ@us.navy.mil, janet.r.cannes.civ@us.navy.mil, and nathan.d.ryan4.civ@us.navy.mil for PSNS & IMF Bremerton. For more information, call (360) 476-0831, (360) 476-8867, or (360) 476-5929. Refer to page 2 for detachment (DET) access instructions. For information regarding Naval Base Kitsap Pass and ID procedures, call (360) 476-4882 or (360) 476-4884.

SECTION I COMPANY OR COMAND INFORMATION

1a. COMMAND AND UNIT IDENTIFICATION CODE OR COMPANY AND CAGE CODE

b. COMMAND OR COMPANY STREET ADDRESS c. CITY d. STATE e. ZIP CODE f. COUNTRY

2a. PURPOSE OF ACCESS

b. CONTRACT NUMBER (FOR CONTRACTOR RED OR YELLOW BADGES)

e. ORGANIZATION, CODE, OR SHOP TO BE VISITED f. ACCESS START DATE g. ACCESS END DATE

SECTION II PERSONNEL REQUIRING BADGES

(ATTACH PAGE 2 FOR ADDITIONAL PERSONNEL)

3a. COMPLETE SSN b. LAST NAME c. FIRST NAME d. MIDDLE

INITIAL

e. SECURITY

CLEARANCE

(NA, C, S, or TS)

f. BADGE COLOR

REQUESTED

(see section III)

g. U.S. CITIZEN (non-classified visitors must bring proof of citizenship)

YES NO

4. VISIT TO:

CIA PSNS & IMF BUILDING (NON-CIA) DET EVERETT DET SAN DIEGO DET YOKOSUKA

Legend: NOT APPLICABLE (NA) CONFIDENTIAL (C) TOP SECRET (TS) SECRET (S) SOCIAL SECURITY NUMBER (SSN) CONTROLLED INDUSTRIAL AREA (CIA)

SECTION III CREDENTIAL REQUIRED

5a. WHITE BADGE (ESCORT AND SECURITY PLAN REQUIRED) c GREEN BADGE (GENERAL UNCLASSIFIED CIA OR DET ACCESS)

b. PSNS & IMF YELLOW BADGE (ACCESS TO UNNPI AND

CONTROLLED NUCLEAR INFORMTION AREAS. DEPARTMENT OF

DEFENSE (DoD) OR DEPARTMENT OF ENERGY (DOE) CLEARANCE

REQUIRED)

d. PSNS & IMF RED BADGE (ACCESS TO NUCLEAR WORK AREAS AND REACTOR COMPARTMENTS. DoD OR DOE CLEARANCE REQUIRED

RECIPIENT MUST HAVE ‘RESTRICTED DATA’ TRAINING )

SECTION III SPONSOR INFORMATION

6a. SPONSOR’S NAME (TENANT SECURITY MANAGER REQUIRED FOR TENANTS) b. SPONSOR’S SIGNATURE

c. BADGE NUMBER d. CODE, SHOP, OR VESSEL e. PHONE NUMBER

PSNS&IMF 5512/127 (Rev. 5-2024) (Front) PREVIOUS EDITIONS ARE OBSOLETE mailto:james.l.lloyd@navy.mil mailto:janet.r.cannes@navy.mil mailto:nathan.d.ryan@navy.mil

CUI (when filled in)

CUI (when filled in)

VISITOR ACCESS AND BADGE REQUEST (CONT.)

SECTION II PERSONNEL REQUIRING BADGES (continued)

3a. COMPLETE SSN b. LAST NAME c. FIRST NAME d. MIDDLE

INITIAL

e. SECURITY

CLEARANCE

(NA, C, S, or TS)

f. BADGE COLOR

REQUESTED

(see section III)

g. U.S. CITIZEN (non-classified visitors must bring proof of citizenship)

YES NO

SECTION IV PSNS & IMF DET ACCESS

Sponsor submits this form to the site security representative if DET access is needed.

Everett: As assigned

San Diego: Lawrence Rosenblatt lawrence.e.rosenblatt.civ@us.navy.mil

Japan: Deogracias Pineda or Daniel Zapata deogracias.g.pineda.civ@us.navy.mil , daniel.m.zapata.civ@us.navy.mil

SECTION V ADDITIONAL GUIDANCE

1. Complete SSNs are necessary for access vetting and credential creation. DoD identification number, or other number identifiers are not a suitable alternative.

2. Sections II: indicate clearance and status. Examples include, confidential, interim secret, secret, top secret, or NA.

3. Access granted, if any, will match the level required to accomplish the purpose for access. Classified visits (red or yellow badges) also require a Defense Information Security System visit request to Security Management Organization 002515.

4. Visitors or contractors are limited to 1 year. Tenant personnel and forces afloat are eligible for 3 year access upon security manager or trusted agent submission

5. Sponsor must be a PSNS & IMF employee or PSNS & IMF approved trusted agent.

PRIVACY ACT STATEMENT

AUTHORITY: Defense Biometric Identification Data System (DBIDS) (DMDC 10 DoD): 10 U.S.C. 113, Secretary of Defense; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and Resources and the DoD Physical Security Review Board (PSRB); DoD 5200.08-R, Physical Security Program; and E.O. 9397 (SSN), as amended. PRINCIPLE PURPOSE: The primary use of this form is by the Security Division (Code 1120) to collect information to adjudicate access to PSNS & IMF and maintain visit statistics. The records support DoD physical security programs, to issue individual facility/installation access credentials, and for identify verification purposes. The records may be accessed by other physical access control systems for further verification at other sites. Records may also be used for law enforcement purposes. ROUTINE USES: Information is used by Code 1120 to determine basis for badging. In addition to those disclosures generally permitted under 5 U.S.C. 552(a)(b), the records contained herein may be specifically disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: law enforcement routine use, Congressional inquiries disclosure routine use, disclosures required by international agreements routine use, disclosures to DOJ for litigation routine use, disclosure of information to NARA routine use, data breach remediation purposes routine use, and DoD blanket routine uses. DISCLOSURE: Furnishing your SSN, as well as other data, is voluntary, but failure to do so may result in denial of access to Naval Base Kitsap, or PSNS & IMF (or both).

PSNS&IMF 5512/127 (Rev. 5-2024) (Back) mailto:james.h.otterholt2.civ@us.navy.mil mailto:lawrence.e.rosenblatt.civ@us.navy.mil mailto:deogracias.g.pineda.civ@us.navy.mil mailto:daniel.m.zapata.civ@us.navy.mil