Sensitive_Security_Information_Acknowledgement_Form.docx
DOCX document 20 KB Posted
- Attached to
- Employee Health Clinic Services
- Solicitation number
- RFP PS-26-0095
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Sensitive Security Information Acknowledgement Form for the City of Phoenix Aviation Department related to an Employee Health Clinic Services contract in Arizona. The form serves as a template to be completed for any project involving documents containing Sensitive Security Information as controlled under 49 C.F.R. Parts 15 and 1520. The document requires authorized company representatives to acknowledge receipt of security-controlled materials and commit to disclosure limitations based on "need to know" requirements as defined in federal regulations. Signatories must agree to destroy the referenced documents upon the earlier of either completion of their need to review and use the materials or by the contract end date specified in the agreement.
The acknowledgement form establishes legal compliance with federal transportation security regulations and protects against unauthorized release of sensitive information, which may result in civil penalties or other enforcement actions. The form requires completion of specific fields including document titles, project names, contract end dates, company name, authorized representative information, title, contact details, and company address. All individuals and organizations receiving documents controlled under these federal regulations must execute this acknowledgement to demonstrate understanding of their obligations regarding information protection and proper destruction procedures.
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Text version
EXHIBIT __
City of Phoenix Aviation Department Sensitive Security Information Acknowledgement Form
The documents entitled [fill in document title(s)] (“Documents”) to be used as part of the [fill in project name] contain Sensitive Security Information that is controlled under 49 C.F.R. Parts 15 and 1520. These documents may only be disclosed to persons who have the requisite “need to know”, as defined in 49 C.F.R. Parts 15 and 1520. Unauthorized release of this information may result in civil penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 C.F.R. Parts 15 and 1520.
I acknowledge, on my behalf and that of my company, the above statement and agree to destroy the [fill in document title(s)], in compliance with 49 C.F.R. Parts 15 and 1520, upon the earlier of our company’s completion of our need to review and/or use the Documents or no later than [fill in current contract end date].
NAME OF COMPANY
AUTHORIZED REPRESENTATIVE PRINTED NAME
AUTHORIZED REPRESENTATIVE’S SIGNATURE
| ______ | ||
| TITLE | PHONE NUMBER |
ADDRESS CITY, STATE AND ZIP CODE
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