RFP Attachment (7)_Form 1B -Security_ServicesRequestForm_Supplemental.pdf

Department of Veterans Affairs VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

SECURITY VERIFICATION CONTINUATION

INSTRUCTIONAL FORM 1B

(This form is used only when extra space is needed for large rosters and must be submitted with a signed form 1a.)

A Contracting Officer Name & Phone: Please list the post-award contracting officer or specialist handling this task order and phone number.

B COTR Name & Phone: Please list the Contracting Officer Technical Representative and phone number. The COTR is the liaison between the contracting officer and contracted company.

C Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station. Should the task order number change at fiscal year end, please indicate this on any future request worksheets by listing the old task order number in parenthesis.

D Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

E Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information. This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

F Employee Name: Please provide the full legal name of the individuals working on this task order. If the individual is working on multiple task orders, please list them again as our database tracks contract statistics.

G SSN: Please provide complete social security numbers for all individuals listed.

H Email Address: Please provide a valid email address for all individuals. This email address will be provided for EQIP communication.

I DOB: Please provide date of birth for all individuals listed.

J Place of Birth: Please provide place of birth for all individuals listed, including city, state and country. For foreign-born individuals, please provide proof of citizenship.

Revised Form November 2018

Department of Veterans Affairs VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSC.Security@va.gov

CONTRACT SECURITY VERIFICATION REQUEST SUPPLEMENTAL FORM

#1B

(This form is used only when extra space is needed for large rosters and must be submitted with a signed form 1a.)

A Contracting Officer Name & Phone:

B COTR Name & Phone:

C Task Order Number:

D Contract Company Name (Subcontractor):

E Contractor POC Name & Phone:

F G H I J Employee Name

(Full Legal Name) SSN Email Address D.O.B. Place of Birth (City, State/Country)

1b1: