RFP 283-22-0568_Attach19a e-QIP Forms.pdf

RFP No.283-22-0568 Attachment 19a

Request for Security Services (Attachment B)

� Badge Request Only (investigation complete - EMP) � Fingerprints & Badge (special cases - FAUF) � Complete Investigation (FAUF)

Applicant: ___________________________________________________________________________ First Middle Last

Applicant is a: � New Federal Applicant � Current Federal Employee � Contractor

Requesting Organization: � ACF � AoA � OS � AHRQ � SAMHSA � PSC � Other ___________

Sub-agency: _____________________ Division: ________________ � HQ � Region __________

Requesting Agency’s CAN #: ______________ Funds Available (initials) ________ � Special Project _______ (Required for processing and billing)

Cost Center Code: ____________________ To be completed by PSC offices only

Sponsor’s Name: ____________________________ Sponsor’s telephone: ______________________

Has applicant ever had an investigation? If yes, when____________________ by who____________________

Is applicant a UFMS User? �yes or �no Is applicant in an IT position with Admin rights? �yes or �no

Type of investigation requested:

____ Level 1 – NACI ____ Level 2 – ANACI or NACLC ____ Level 3 – SSBI

____ Level 5 – LBI ____ Level 5 – MBI (Required for UFMS Access)

____ Level 6 – BI (Required for IT Admin rights)

____ Other (state type) ____________________

Application Packet Check List:

Fingerprints: _____ Electronic - Date prints taken: __________ Location: _____________________

_____ SF-87 Attached (Federal Employees) _____ FD 258 Attached (Contractors)

Other Forms: _____ E-QIP Initiation Form _____Hard Copy Questionnaire (Special Case)

_____ HHS 207 (Secret and Top Secret only)

_____ HHS ID Badge Request (HHS-745)

Submitted by: ______________________________ Date: ____________________________ (Sponsor’s Signature)

Submit packets to: PSC/SSB 5600 Fishers Lane room 4B-44 Rockville, MD 20857

RFP No.283-22-0568 Attachment 19a

E-QIP Initiation Request Form: (Attachment C)

To: Security Services Branch Date: ________________ Parklawn Building, Room 4B-44 5600 Fishers Lane Rockville, MD 20857

In line with new regulations mandated by the U.S. Office of Personnel Management, Investigative Services and the Department of Health and Human Services, we are implementing the Electronic Questionnaires for Investigative Processing (EQIP) System. As a result, electronic submission of the SF-85, SF-85P, and the SF-86 is now required.

In accordance with Executive Order 10450 and the Homeland Presidential Directive 12 (HSPD-12) all Federal Employees and Contractors are required to hold at a minimum a NACI suitability investigation in order to obtain Federal Employment or to work on a Federal Contract.

The following information is required in order to initiate the applicant into the EQIP system. After the applicant has been initiated into the EQIP system they will receive an email from the Security Services Branch with instructions on how to access the system and any additional forms required to complete the process.

Instructions to applicant:

Please type or print your information legibly and return this form to your sponsor for forwarding to the PSC/SSB.

Walk-in applicants will not be accepted.

1. Full Legal Name: ___________________________________________________________________ First Middle Last

2. Place of Birth: _____________________________________________________________________ City State Country

3. Date of Birth: _____________________________________________________________________ Month Day Year

4. Social Security Number: _____________________________________________________________

5. Position/Title: _____________________________________________________________________

6. Applicant’s Work Location: ___________________________________________________________

7. Applicant’s daytime phone #: _________________ Applicant’s e-mail address ___________________

8. Do you currently or have you ever held a security clearance? � yes � no

To be completed by PSC/SSB

E-QIP ID #

E-QIP initiation assigned to: _________________________________ Date: __________________________ (Print Specialist’s Name)

Entered into BITS database by: _____________________________ Date: __________________________ (Print Name)