UTNG G2 LF 001- SECURITY SCREENING FORM 2019 FINAL PDF.pdf

FOR OFFICIAL USE ONLY (WHEN FILLED IN)

SECURITY SCREENING/DECLARATION

PRIVACY ACT STATEMENT

AUTHORITY: Executive Order (E.O.) 10450, Security Requirements for Government Employees; 5 CFR 731.202, Suitability Determinations, E.O. 12958, Classified National Security Information; and E.O. 12968, Access to Classified Information, are the authorities for soliciting information during this interview. 10 U.S.C. 8013, and E.O. 9397 (SSN), SEAD-3 “Reporting Requirements for Personnel with Access to Classified Information or Who Hold a Sensitive Position”.

PURPOSE: SSN is used for positive identification and will assist in determining the acceptability of an individual for nomination, retention, or further processing for suitability or security determinations.

ROUTINE USES: This form serves an addendum to the OF-306 for pre-employment screening. This form is used to screen individuals for access to UTNG facilities when a full background investigation is not required. It can also be used to update background investigations or for pre-deployment screening. It is also used as part of the UTARNG Continuous Evaluation Program. Any information developed during this interview may be disclosed to Federal, state, or local authorities.

DISCLOSURE: Disclosure is voluntary; however, failure to provide the requested information may result in reassignment to non-sensitive duties, unfavorable suitability determinations, withdrawal of employment offers, or suspension of classified access.

NAME: (Last) (First) (Middle) (Maiden) SSN:

DATE OF BIRTH: UNIT/ORGANIZATION: PHONE# (Cell or Home)

Part I: CRIMINAL, FINANCIAL, and BEHAVIORAL HEALTH ISSUES

INSTRUCTIONS: Please answer TRUTHFULLY by checking the box if the statement applies to you. For each statement that is checked, please cite the line number and provide additional details, to include circumstances of the activity or association, and current status, on a continuation sheet and attach to this form.

1: CHECK YES (Y), IF IN YOUR LIFETIME, HAVE YOU EVER BEEN CHARGED WITH….

Y N A: A felony of any type Y N E: Child abuse or domestic violence related offense?

Y N B: A firearms or explosives-related offense? Y N F: A sex-related offense?

Y N C: An offense related to alcohol or drugs? Y N G: An espionage or terrorism-related offense?

Y N D: An offense related to sabotage or destruction of U.S. Government property?

Y N H: An offense related to the misuse of any U.S government information system?

2: CHECK YES (Y), IF YOU ARE CURRENTLY, OR WITHIN THE LAST SEVEN (7) YEARS, YOU HAVE BEEN …

Y N A: Arrested or charged with a criminal offense? Y N E: Issued a summons, citation, or ticket to appear in any court, to include a minor traffic offense?

Y N B: The subject, or a person of interest, in a criminal investigation?

Y N F: The defendant of a lawsuit, litigation, or other legal issue?

Y N C: On probation or parole? Y N G: Required to register as a sex offender?

Y N D: The subject of a court-issued protective order or stalking injunction?

Y N H: The subject of any outstanding warrants or criminal charges that are pending against you?

3: CHECK YES (Y), IF YOU ARE CURRENTLY, OR WITHIN THE LAST SEVEN (7) YEARS, YOU HAVE …

Y N A: Been voluntarily admitted or involuntarily committed to a hospital for a severe mental illness?

Y N C: Received either voluntary or involuntary treatment or counseling due to alcohol or drug use?

Y N

B: Illegally used, possessed, bought, sold, or transferred any illegal drug or controlled substance, or abused any prescription drug medication? Examples include usage of marijuana, cocaine, crack, hashish, narcotics (opium, morphine, codeine, heroin, etc.), hallucinogenic (LSD, PCP, etc.), amphetamines, or depressants (barbiturates, methamphetamines, tranquilizers, etc.)

Y N

D: Been diagnosed or received treatment, for a serious mental health condition that would affect your judgment, reliability, or impact your ability to protect classified information or other sensitive information? Examples include bipolar disorder, schizophrenia, Class B personality disorder, etc. DO NOT report counselling or treatment for depression, PTSD, grief, marital or family counselling, etc.

4: CHECK YES (Y), IF YOU CURRENTLY, OR WITHIN THE LAST SEVEN (7) YEARS, HAVE HAD…

Y N A: To file for any type of bankruptcy? Y N F: Any delinquency over 180 days on any debt?

Y N B: Any credit judgments (paid or unpaid)? Y N G: Any foreclosure or repossession of property?

Y N C: Any wage garnishments (paid or unpaid)? Y N H: Any accounts in collections, or charged off accounts?

Y N D: Any liens placed on your property? Y N I: Any failure to pay federal, state, or local taxes?

Y N E: Any delinquency on child support or alimony payments?

Y N J: Any delinquency on paying a federal or state student loan, or tuition?

Part II: FOREIGN CITIZENSHIP, CONTACTS, TRAVEL, AND ASSOCIATIONS

5: CHECK YES (Y), IF YOU…

Y N A: Are a citizen of another country OTHER than the United States? LIST COUNTRIES:

Y N B: Maintain dual citizenship with the United States and another country?

Y N C: Possess a foreign passport or government-issued identification card?

Y N D: Have voted, or you plan to vote in an upcoming foreign election?

Continued on Next Page

FOR OFFICIAL USE ONLY (WHEN FILLED IN)

6: CHECK YES (Y), IF YOU ARE CURRENTLY, OR WITHIN THE LAST TWELVE (12) MONTHS, YOU HAVE…

Y N A: Been employed by or had direct involvement with a foreign corporation or business?

Y N B: Owned or managed any foreign property, investment, or foreign bank account?

Y N C: Functioned as an employee, volunteer, agent, or representative of a foreign government?

Y N D: Communicated or interacted with a known or suspected agent of foreign intelligence service or law enforcement agency?

Y N E: Traveled to a foreign country or territory that you have NOT previously reported to your security official? Note:

Please exclude individual and unit mobilizations and official government travel

Y N F: (SCI ONLY) Established any new or additional close and continuing contacts with a foreign national that you have NOT previously reported to your Security Official? Please exclude un-planned, non-recurring casual contact.

Y N G: Married, divorced, cohabitated with, or became engaged to, an individual who is NOT a U.S. Citizen?

Y N H: Legally changed your name, proposed to legally change your name, or used an alternate name or identity?

7: LIST IMMEDIATE MEMBERS OF YOUR FAMILY WHO ARE NOT U.S. CITIZENS (include, full steps/halves parents and siblings; children; spouse, in-laws, cohabitants and/or fiancé(e)s). ALSO LIST ANYONE LIVING IN YOUR HOUSEHOLD WHO IS NOT A U.S. CITIZEN (include roommates, tenants, foreign exchange students, etc.). NOTE:

U.S. CITIZENS BORN ABROAD TO U.S. PARENTS DO NOT NEED TO BE LISTED.

FULL NAME RELATIONSHIP DATE OF BIRTH PLACE OF BIRTH CITIZENSHIP

Part III: SIGNATURE AND CERTIFICATION OF CONSENT

My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form may disqualify me or can be punished by fine or imprisonment or both. (See section 1001 of Title 18, United States Code). I consent to record checks of publically available information in conjunction with these statements.

INDIVIDUAL SIGNATURE DATE

REMARKS AND EXPLANATIONS (ATTACH A SEPARATE CONTINUATION SHEET IF NECESSARY):