Attachment_V_Bonneville-WFL-SRS_Access_Request_(part_A)_2017-04-04.pdf

NWP Projects Access Request (part A) 2017‐04‐04.docx

USACE PORTLAND DISTRICT (NWP)

ACCESS REQUEST FORM (Part A – Personal Data)

All documents must be submitted a minimum of one business day (Mon‐Thurs) before access is required (2 business days if requesting unescorted Powerhouse access).

If requesting unescorted Powerhouse access, a 7 year background check, completed NERC CIP quiz, and HECP Affected Person certificate are required.

DATA REQUIRED BY THE PRIVACY ACT OF 1974 (5 U.S. CODE 552a) AUTHORITY AR 600‐8‐14, AR 600‐8‐104, NERC Standard CIP‐004, and USACE Portland District (NWP) Cyber Security Policy.

PRINCIPAL PURPOSE To establish positive identification of all personnel requiring access to NWP projects and facilities, including U.S. Government employees, Contractors, Foreign National employees, and authorized visitors. Also included are non‐affiliated agencies and groups granted special access by the U.S. Government.

MANDATORY DISCLOSURE REQUIREMENT Failure to provide the below requested information, including date of birth, place of birth, citizenship, and/or driver’s license number, if required, will result in the disapproval of this application. Disapproved applicants will be denied issue of a Project ID/Access Badge and access onto NWP District controlled facilities.

Personal information such as date of birth, place of birth, citizenship, and/or driver’s license identification provides an individual with a unique identification and will be handled as FOR OFFICIAL USE ONLY in accordance with Federal Statutes.

CONDITIONS APPLICABLE ON RECEIPT I understand that the Project ID/Access Badge is valid only through the expiration date indicated. Its intended use and authorizations are limited to those indicated on this form and the card. I understand that the Project ID/Access Badge is US Government property, that it is not transferable, that it is not to be altered in any way, and that it must be surrendered upon request of the US Government, its designated representative, or the issuing agency. I understand that while on any NWP property, my person, possessions, vehicle and work area are subject to search at the discretion of the US Government or its designated representative. I understand that I may be held liable for the cost of replacement for my Project ID/Access Badge if lost.

SECTION I – SPONSORSHIP

1 NWP Project where access is requested

Bonneville Lock and Dam/WFL/SRS

John Day Dam/Willow Creek

Willamette Valley

Rogue River

2 Area(s) where access is needed

3 Activity/project/contract for which access is needed

4 Dates of Access Requested

From ________________ To ________________

5 Work Hours

From ______________ To _______________

6 Work Days

___ Su ___ Mo ___ Tu ___ We ___ Th ___ Fr ___ Sa

7 POC/Sponsor Name

8 POC/Sponsor Email

9 POC/Sponsor Phone

POC/Sponsor: Complete this section for Non‐USACE Personnel 10 Project Name/Task Order

11 Contract Number

12 End of Contract Date

13 Prime Contractor (if applicable)

14 Prime Contractor Email

15 Prime Contractor Phone

16 COR

17 COR Email

18 COR Phone

SECTION II – PERSONAL DATA

19 Last Name

20 First Name

21 Middle Name/Initial

22 Suffix

23 Phone

24 Email

25 Company (or office code if applicable, e.g. CENWP‐OD‐B)

26 Supervisor

27 Supervisor Phone

List the TYPE of photo ID you will use when you claim your badge. CAC or TWIC is preferred if available.

(Provide two IDs if primary ID is not REAL ID compliant – see back of page for requirements)

28 ID Issuing Authority/Agency (CAC, TWIC, state for DL, etc.)

29 ID Expiration Date

30 Place of Birth

31 U.S. Citizen?

Yes No* 32 Foreign Visitor Authorization Code

*Non‐U.S. citizens (including personnel with permanent resident status) must obtain Foreign Visitor Authorization BEFORE initiating this access request.

SECTION III – ACKNOWLEDGMENT

All applicants requiring access to NWP facilities must provide the necessary documentation as defined in the access policy instructions. This documentation may include personal identification documents, sponsorship and completed security background checks. Disclosure is voluntary; however failure to supply any of the required information may result in the rejection of the applicant’s request for access. All information will be handled as FOR OFFICIAL USE ONLY and in accordance with applicable Federal Statutes. It should also be known that any derogatory information returned from the applicant’s background investigation may reflect adversely on consideration for access. Any falsification on the form will result in immediate revocation of access privileges.

By signing I certify that all statements in this application are true and correct to the best of my knowledge. I understand that any misrepresentation will be cause for immediate denial of access privileges. I hereby authorize the release of the information requested by NWP District, and any of its sub entities, for the purpose of determining my suitability for access.

33 Applicant Signature

34 Date

NWP Projects Access Request (part A) 2017‐04‐04.docx

REAL ID Act Requirements

Driver licenses and identification (ID) cards that do not comply with the REAL ID Act of 2005 can no longer be used as the sole source for identity proofing for unescorted access to military installations and facilities.

To be Real ID Act compliant, the identification card must be issued by a US State government or the US federal government and it must include the following information:

(1) The person's full legal name.

(2) The person's date of birth.

(3) The person's gender.

(4) The person's driver's license or identification card number.

(5) A digital photograph of the person.

(6) The person's address of principal residence.

(7) The person's signature.

(8) Physical security features designed to prevent tampering, counterfeiting, or duplication of the document for fraudulent purposes.

(9) A common machine‐readable technology, with defined minimum data elements.

As of 10 January 2016, driver licenses and ID cards from the states and territories that do not comply with the REAL ID Act may not be accepted without a second form of ID.

Exception: Enhanced Driver Licenses (EDL) from some states are considered more secure than Real ID Act compliant cards, and can be used as the sole source for identity proofing to access federal facilities and installations. EDL are marked as Enhanced Driver License and bear a small red, white, and blue U.S. flag logo on the front of the card.

For a listing of states and territories that issue identification cards in compliance with the REAL ID Act, visit the Department of Homeland Security website.

https://www.dhs.gov/secure‐drivers‐licenses https://www.dhs.gov/current‐status‐states‐territories