S02 - ATTACHMENT J - VSC Security Request Forms - 2023.pdf

Department of Veterans Affairs VHA 106A WMC HROO PerSecContractor Team

VHAWMCPerSecContractor@va.gov

VHA 106A WMC HROO PerSecContractor Team SERVICES

OVERVIEW

The VHA 106A WMC HROO PerSecContractor Team offers comprehensive services which ensures that contractor security requirements are met in accordance with OPM and federal regulations from initiation to completion.

Communication is maintained between the team POC, the contracting officer, the contracting officer representative (COR) and the contracting company point-of-contact at all times during the process. Due to PII concerns, personnel not listed on the Form #1 will be sent statuses from the Team POC. If another entity requires this information, they must work through the CO, COR or Company POC. This service provided includes the below:

Fingerprint adjudication:

o This involves a thorough background screening and adjudication of fingerprint along with any self- declared information. After the results are confirmed or adjudicated, the National Criminal History Check (NCHC) Form will be sent to all contacts via email.

Existing investigations:

o Verifying existing investigation information and collecting the required documents for reciprocity.

The required documentation would include the OF306 Form and Self-Certification Form. These documents would be provided upon confirmation of investigation through the OPM Portal.

New investigations:

o Upon receipt of the Contract Security Services Request Packet and all required documents our office will enter each applicant into the e-QIP system, review, return or release, and monitor the investigation progress through completion.

PIV Badges:

o Our office can only adjudicate PIV badges at this time. The COR on the contract or local personnel must sponsor the contractor/s in the PIV portal prior to adjudication by this office.

To begin the process, please follow the below guidelines:

1. Upon notification of contract award, make appointments for fingerprinting. Ensure contractors bring Form #2 Fingerprint Request Form and 2 forms of ID to their appointment.

2. Contracting officers, CORs complete and digitally sign the Form #1 in its entirety. All information is required. The packet will be rejected if this form is not complete or does not contain the CO signature.

3. Have employees complete all required documentation based on their risk level.

4. Submit complete packet to VHAWMCPerSecContractor@va.gov encrypted. Incomplete packets will be rejected and returned. Complete packets will be assigned to a team member within 5 to 10 business days dependent on workload. Subject line for the request submission email should be formatted as shown below.

a. New Request Packet - Contracted Company 36C00000D0000 / 999-C202222

b. Status Request – Contracted Company 36C00000D0000 / 999-C20222 submitted on

00/00/0000

5. Do not submit new requests and additions more than once as this will result in duplicate assignments and wasted time. If you have not received a response to your request within 5-10 business days, send a status request to the mailbox using the above format.

6. If there is a change in the contracted personnel (resignation, declined appointment, etc.) immediately notify the team member handling your request. The cancellation must be submitted via email.

7. Send any additions to our team member that is assigned the contract. We cc the sender of this packet on that assignment so that you can work directly with that team member on all associated actions to include re-issuances, turnover, questions, concerns, statuses, etc. If the packet is already assigned and was not forwarded to the assigned member, we will reject that packet. This is so that we can assign the new contracts as fast as possible for you.

mailto:VSC.Security@va.gov mailto:VSC.Security@va.gov

CONTRACT SECURITY SERVICES REQUEST - INSTRUCTIONAL FORM #1A

Purpose: The Contract Security Services Request is submitted to VHA 106A WMC HROO PerSecContractor Team to initiate the contract security verification process. By submitting this form, our office will ensure that everyone listed have been fingerprinted, the fingerprints are adjudicated, if necessary, background investigations are initiated or existing background investigations are current and PIV badges are adjudicated. This form should be completed and signed by the contracting officer. Please refer to the instructions below when completing the Contract Security Services Request Form #1.

Contract Information Section

Contractor Employee Information Section

Employee Name: Please provide the full legal name of the individuals working on this task order.

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

Email Address: Please provide a valid email address for all individuals.

DOB: Please provide date of birth for all individuals listed. (MM/DD/YYYY)

Place of Birth: Please provide place of birth for all individuals listed, including city and state or city and country (if outside US).

N O T E : For foreign- born individuals, please provide proof of citizenship.

Contracting Officer & Phone: Please provide the post-award contracting officer handling this contract and their phone number.

COR Name & Phone: Please list the Contracting Officer Representative (previously the Contracting Officer Technical Representative) and phone number. The COR is the liaison between the contracting officer and contracted company.

Contract End Date: Please list the date in which the contract ends including all options to extend (for PIV badge expiration).

RPO Region: Please list the Regional Procurement Office in which the contracting officer is associated with (East, West, Central). If your contract is not coming from the VHA RPO contracting group or station 776, then we would not process your contracts

VISN & Station Number: Please indicate the VISN and facility station number where the work is being performed/facility to be billed.

Purchase Order, Task Order and Contract Numbers: Please list the purchase order number, task order and the contract numbers. Our database is based on tracking contracts by station. Should the task order number change at fiscal year-end, please indicate on any future requests by including any/all related numbers in parenthesis next to the new numbers.

Contractor Position Description: Please provide a position title for all individuals (ex: physician, consultant, electrician).

Investigation Level: Please indicate the background security requirements as provided by the PDT (Position Designation Tool). This would include background screening or Fingerprint Only (SAC), low-level investigation (Tier 1), moderate-level investigation (Tier 2) and high-level investigation (Tier 4). Please note that PIV-I badges (contract under 180-days) require at minimum a SAC, full PIV badges (over 180-days) require a minimum a T1. If it is Tier 2 or 4, please provide a copy of the PDT to justify a higher-level investigation.

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.

Contractor Address: Please provide the contracting company address.

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 COR.

Contractor POC Email: Please provide the email address for the company point-of-contact. This email will be included in all correspondence regarding investigation and PIV processing.

Contracting Officer Signature: All contracts must be signed by the contract specialist or the contracting officer representative (COR). This signature verifies that an official contract is in place prior to processing the applicants for investigation and badging.

CONTRACT INFORMATION

VHA 106A WMC HROO PerSecContractor Team

CONTRACT SECURITY SERVICES REQUEST

FORM # 1A

(Email to: VHAWMCPerSecContractor@va.gov)(Make sure it is encrypted or password protected)

VA Contracting Officer Name & Phone:

COR Name & Phone:

Contract End Date (Including Options):

RPO Region (East/West/Central):

VISN & Station#:

Purchase/Task Order or Contract Number:

Contractor Position Description:

Investigation Level (SAC/Tier 1/Tier 2/Tier 4):

Contract Company Name (Subcontractor):

Contract Company Address:

Contractor POC Name & Phone:

Contractor POC Email:

Contracting Officer Signature:

***This signature verifies that an official contract is in place prior to processing the applicants for badging***

Contractor Employee Information

Employee Name (Full Legal Name) SSN Email Address D.O.B. Place of Birth

(City, State/Country)

*Please use Continuation Form # 1B for additional individuals*

Current as of January 2023

VHAWMCPerSecContractor@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.

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

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

Task Order Number: Please list the purchase order, contract and task numbers. Our database is based on tracking contracts by station. Should the purchase order, contract and task numbers change at the end of the fiscal year, please indicate this on any future request worksheets by listing the old task order number in parenthesis.

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.

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 COR.

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.

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

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

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

Place of Birth: Please provide place of birth for all individuals listed, including city and state or city and country.

Note: For foreign-born individuals, please provide proof of citizenship.

Revised Form January 2023

VHA 106A WMC HROO PerSecContractor Team

VHAWMCPerSecContractor@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 COR Name & Phone:

C Task Order/Contract/PO Numbers:

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)

CONTRACTOR / EMPLOYEE FINGERPRINT REQUEST INSTRUCTIONAL FORM 2A

Purpose: The Contractor/Employee Fingerprint Request is to assist individuals in obtaining fingerprinting services from VA Facilities nationwide, on behalf of the WMC.

A Full Legal Name: Please provide full legal name of individual requiring fingerprints.

B SSN Last Four: Please provide the last four of the individual’s social security number.

C Contractor (Yes/No): Please indicate whether the individual is a contractor. Contracted employees are considered contractors.

D VAMC Location: Please provide the name and location of the VA Facility where the fingerprints were submitted.

E Station Number: Please provide the station number of the VA Facility where the fingerprints were submitted.

F Date Fingerprinted: Please provide the date that the fingerprints were submitted at the VA Facility.

G Method of Fingerprinting: Please indicate whether the fingerprints were submitted electronically or if manual fingerprints were submitted with ink and fingerprint card.

H Date Card Mail to OPM: If fingerprints were submitted manually, please provide the date the card was mailed to

NOTE: PLEASE ENSURE FULL NAME IS CORRECT AND CONFIRMED ON ID

Revised Form January 2023

VHA 106A WMC HROO PerSecContractor Team

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200

(Please see Instructional Form #2a for assistance in completing this form)

** This form must be taken to the fingerprinting appointment **

EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor/Federal/Other:

NOTE: PLEASE ENSURE FULL NAME IS CORRECT AND CONFIRMED ON ID

FACILITY INFORMATION

D VAMC Name & Location:

E PIV Office Official :

F Date Fingerprinted:

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSCSecurity@va.gov

PIV SPONSORSHIP INSTRUCTIONAL FORM 3A

Purpose: The PIV Sponsorship Form is used to complete the PIV badge application through the nationwide portal. All information is required to process a PIV badge. All fields are mandatory except the VA.GOV email address.

A Full Legal Name: Please provide full legal name of individual as shown on driver’s license or photo ID.

B Date of Birth: Please provide the date of birth of the individual.

C Social Security Number: Please provide the social security number of the individual.

D Citizenship: Please provide the citizenship of the individual. All foreign-born individuals will be required to submit proof of citizenship.

E Assigned Duty Station: Please provide the name of the individual’s assigned duty station.

F Address of Assigned Duty Station: Please provide the complete address of the assigned duty station.

G VA.GOV Email Address: Please provide the va.gov email address of the individual. If the individual has not had the email address established, or will not be obtaining an email address, please indicate pending or not applicable.

H Gender: Please provide gender of individual.

I Race: Please provide race of individual.

J Height: Please provide height of individual.

K Weight: Please provide weight of individual.

L Eye Color: Please provide eye color of individual.

M Hair Color: Please provide hair color of individual.

N Place of Birth: Please provide city, state and country of individual’s place of birth.

All foreign-born individuals will be required to provide proof of citizenship.

O Position Title: Please provide position title of individual.

P Contractor Company Name: Please provide the contracting company that the individual will be working under. If the individual is a VA employee, please indicate not applicable.

Q Contracting Company Address: Please provide the contracting company address. If the individual is a VA employee, please indicate not applicable.

Revised Form April 2012

VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSCSecurity@va.gov

VHA SERVICE CENTER PIV SPONSORSHIP FORM #3

(Please see Instruction Form #3a for assistance in completing this form)

CONTRACTOR / EMPLOYEE INFORMATION

* All fields are mandatory except va.gov email *

A Full Legal Name (First Middle Last):

B Date of Birth (MM/DD/YYYY):

C Social Security Number:

D Citizenship: (US Citizen, Naturalized, Non-Citizen)

E Assigned Duty Station:

F Address of Assigned Duty Station:

G VA.GOV Email Address:

H Gender:

I Race:

J Height:

K Weight:

L Eye Color:

M Hair Color:

N Place of Birth (City, State, Country):

O Position Title:

P Contractor Company Name:

Q Company Address:

Self Certification Form (June 2022 Version)