ATTACHMENT_B_Background_Investigation_Worksheet.docx

Attachment B: Background Investigation Worksheet (RPSC) VA119A-17-R-0010

ATTACHMENT B: BACKGROUND INVESTIGATION WORKSHEET

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Revised September 2015

SECURITY USE ONLY

SAC: Previous Investigation: Record:

VBA Contractor Background Investigation Request Worksheet

ALL FIELDS ON THIS FORM ARE MANDATORY INCLUDING APPLICANT EMAIL

Where Applicant Will Work City, State, Station #

Station to be Billed for Clearance Washington, DC #101

□ New □ Transfer □ Addition

Please provide the following information for each contract employee:

Applicant’s Full Name First Name, Middle Name (or NMN), Last Name

Social Security Number

Date of Birth

Email

Place of Birth City, State, Country

Position/Job Title

Does applicant have a clearance pending or completed with OPM? YES NO

Type of Investigation Requested BI (High Risk) MBI (Moderate Risk) NACI (Low Risk)

Is applicant a foreign national? YES NO

VA Contracting Officer Representative (COR)

VA COR Telephone Number

COR’s Mail Routing Symbol

VA COR Email

Address

City, State, Zip

Prime Contracting Company Name

Prime Contracting Company POC

POC Telephone

POC Email

Address

City, State, Zip

Contract Title

Purchase Order Number (Ex: J37243)

City State Station:

New: Off

Transfer: Off

Addition: Off

First Name Middle Name or NMN Last Name:

1:

2:

3:

4:

undefined:

NO:

BI High Risk:

NO_2:

1_2:

2_2:

3_2:

4_2:

5:

6:

Prime Contracting Company Name:

Prime Contracting Company POC 1:

Prime Contracting Company POC 2:

Prime Contracting Company POC 3:

Prime Contracting Company POC 4:

Prime Contracting Company POC 5:

Prime Contracting Company POC 6:

Purchase Order Number Ex J37243:

Check Box1: Off

Check Box2: Off

Check Box3: Off

Check Box4: Off

Check Box5: Off

Check Box6: Off

Check Box7: Off

Check Box8: Off

Check Box9: Off

Check Box10: Off