OG3. Personnel Security Questionnaire.pdf

Classify as appropriate when filled-in

Pre-Screening Questionnaire

Pre-Screening Questionnaire (PSQ), March 31, 2021 Privacy Sensitive – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulations (CFR).

Classify as appropriate when filled-in

Name: SSN: _____________________________________

City, State, and Country of Birth: _________________________________________________________________

Date of Last Completed Investigation: _____________________________________________________________

I certify my answers on this questionnaire and attached templates are true, complete, and accurate to the best of my knowledge:

Nominee’s Signature: Date:

For all “Yes” responses please provide supplemental information on the corresponding template

• PSQ Template 1 - Foreign Affections

• PSQ Template 2 - Foreign Associations

• PSQ Template 3 - Foreign Travel

• PSQ Template 4 - Personal Conduct

• PSQ Template 5 - Financial Responsibility

Questions (Y/N)

1) Foreign Affections: Is any of your immediate family a citizen of a country other than the United States or do you or anyone in your immediate family claim dual citizenship? (Immediate family is a spouse, parent, sibling, child, cohabitant, step-parents, half- and step-siblings, and step-children of the subject.)

2) Foreign Associations:

Foreign Associations: Do you, your spouse or cohabitants have any continuing contact with citizens or dual citizens of a country other than the United States?

(Reporting is not required if contact with a foreign national only occurs while in the performance of official United States Government business.)

Foreign Assets: Do you, your spouse, and/or cohabitant have any financial interest or assets in a country other than the United States?

3) Other Than Official Government Foreign Travel: Have you visited any foreign countries since your last completed investigation?

4) Personal Conduct: Has your clearance or access been suspended, denied or revoked; or have you been arrested since your last completed investigation?

5) Financial Responsibility: Have you had any bills referred to a collection agency, had your wages garnished, have any tax liens against you or filed for bankruptcy since your last completed investigation?

INSTRUCTIONS FOR COMPLETING THE PRE-SCREENING QUESTIONNAIRE

NAME: Provide your complete name - Last, First, MI, (suffix, Jr, III, etc.) (Smith, John M.)

SSN: Provide your complete 9-digit SSN (123-45-6789)

CITY, STATE, COUNTRY OF BIRTH: (Ex: Richmond, VA, United States (U.S.))

DATE OF LAST COMPLETED INVESTIGATION: If known, provide the date (MM/DD/YYYY) for the closure date of your most recent investigation or date enrolled into Continuous Evaluation (CE) upon deferment of your periodic reinvestigation (PR). If you do not know this information, contact your security POC.

QUESTIONS:

1. FOREIGN AFFECTIONS:

A foreign affection applies when you or an immediate family member is a citizen of a country other than the U.S.

This includes yourself or immediate family members who may be U.S. citizens but also claim citizenship in one or more other countries. Immediate family members include a spouse, parent, sibling, child, cohabitant, step-parents, half- and step-siblings, and step-children.

YES: you must complete Template 1 – Foreign Affections if you can answer YES to any part of this question. Each foreign affection must be listed on a separate template; do not list multiple foreign affections on the same template.

NO: only if you can answer NO to Question 1 in its entirety. Do not complete a PSQ Template for No answers.

2. FOREIGN ASSOCIATES:

A foreign associate is a person whom you, your spouse, or cohabitant socialize with OUTSIDE of the performance of official U.S. Government business where you, your spouse, or cohabitant have personal continued, frequent and/or ongoing communications (including foreign social media contacts, internet contacts, and/or the exchange of personal information), who is known NOT to be a citizen of the U.S. or known to be a dual citizen claiming citizenship to one or more countries including the U.S.

FOREIGN ASSETS:

Foreign assets are bank accounts, investments, holdings, businesses, finances, real estate, or any other financial interest or assets associated with or conducted in a country other than the U.S.

YES: you must complete Template 2 – Foreign Associates if you can answer YES to any part of this 2-part question.

Each foreign associate/asset must be listed on a separate template; do not list multiple foreign affections/assets on the same template.

NO: only if you can answer NO to Question 2 in its entirety. Do not complete a PSQ Template for No answers.

3. OTHER THAN OFFICIAL GOVERNMENT FOREIGN TRAVEL:

Since your last investigation/PR deferment date into CE, list foreign travel not related to U.S. government business outside the borders of the U.S. and its territories that was done for personal or company business, volunteer, education, tourism, visiting family/friends, trade shows, conferences, seminars, etc. This includes visits to foreign embassies within the U.S. and abroad. Travel funded by the U.S. Government either directly or billable to a U.S.

Government contract is considered official government foreign travel. Foreign travel for business development must be reported unless the company has specifically been directed to travel on behalf of the U.S. Government. Provide information in remarks section as to whom you visited (foreign national, EXPAT, Active Duty military assigned abroad, etc.). Completing this PSQ template does not alleviate your responsibility to report foreign travel to your security manager.

YES: you must complete Template 3 – Foreign Travel if you have conducted foreign travel since your last investigation/PR deferment date into CE. Each foreign travel trip must be listed on a separate template; one trip with multiple destinations should be listed on one template.

NO: only if you can answer NO to Question 3 in its entirety. Do not complete a PSQ Template for No answers.

4. PERSONAL CONDUCT:

Personal conduct refers to reporting information which may have an impact on clearance eligibility or suitability.

Reporting requirements include all suspensions, denials, revocations, and arrests regardless of outcome (charged, charges dropped, withdrawn, etc.), since your last investigation/PR deferment date into CE.

YES: you must complete Template 4 – Personal Conduct if you can answer YES to any part of this question.

Only one personal conduct report per template.

NO: only if you can answer NO to Question 4 in its entirety. Do not complete a PSQ Template for No answers.

5. FINANCIAL RESPONSIBILITY:

Financial responsibility refers to the timely payment of financial obligations. Bills referred to collection agencies, garnished wages, tax liens, bankruptcies, lawsuits, judgements, etc., since your last investigation/PR deferment date into CE must be reported.

YES: you must complete Template 5 – Financial Responsibility if you can answer YES to any part of this question.

Each financial responsibility report must be listed on a separate template; do not list multiple on the same template.

NO: only if you can answer NO to Question 5 in its entirety. Do not complete a PSQ Template for No answers.

When you have fully completed, sign (ink or digitally) and date the form.