OG3. PSQ Template 3 - Foreign Travel (20160712).pdf

PSQ TEMPLATE 3 - FOREIGN TRAVEL

PSQ Template 3 - Foreign Travel, July 12, 2016

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide 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

Report all non-official U.S. Government foreign travel since your last completed investigation. If itinerary included more than one foreign country, list all countries visited. Do not list travel under official U.S. Government business, but you must include any personal trips to other countries made in conjunction with the official U.S.

Government travel. If you have lived near a border country and have made short (one day or less) trips to the neighboring country (e.g. Canada or Mexico), you do not need to list each trip. Instead, provide the time period, the code, the country, and a remark (e.g. "Many Short Trips").

NOMINEE’S FULL NAME __________________________ SSN __________________

Have you reported the information disclosed on this form to your local security officer?

__ Yes __ No If yes, date information was reported:___________________ Estimated? __ Yes __ No Use these codes to indicate the purpose(s) of your visit:

1-Business/Professional (other than official U.S. Government) 2-Volunteer activities 3-Education 4-Tourism 5-Visit family/friends 6-Trade show, conference, seminar 7-Other

Code ___ If other explain __________________________ Date of Travel (month/year) _________________________ Number of days ______ Country/Countries & Cities: ______________________________________________________

1. Did you deviate from the itinerary you provided prior to your departure? __ Yes __ No If yes, explain __________________________________________________________________

2. While traveling to, or in this country/countries, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when you entered or left this country? __ Yes __ No If yes, explain ______________

3. While traveling to, or in this country/countries were you involved in any encounter with the police or did you experience any security issues? __Yes __ No If yes, explain ______________

4. While traveling to, or in this country/countries, were you contacted by, or in contact with, any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organization? __ Yes __ No If yes, explain _________________________

PSQ TEMPLATE 3 - FOREIGN TRAVEL

PSQ Template 3 - Foreign Travel, July 12, 2016

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide 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

5. While traveling to, or in this country/countries, were you contacted by, or in contact with, anyone exhibiting excessive knowledge of, or undue interest in, you or your job? __ Yes __ No If yes, explain __________________________________________________________________

6. While traveling to, or in this country/countries, were you contacted by, or in contact with, anyone attempting to obtain classified information or unclassified, sensitive information (i.e., FOUO)? __ Yes __ No If yes, explain _____________________________________________

7. While traveling to, or in this country/countries, were you threatened, coerced, or pressured to cooperate with a foreign government official or foreign intelligence or security service?

__ Yes __ No If yes, explain: ____________________________________________________

Remarks:

NOMINEE’S SIGNATURE_____________________________________

DATE_________________________