PSC 29

Document Sample
PSC 29 Powered By Docstoc
					                                           Personal Identity Verification (PIV) Request
                                                     Government Employees
                                                                  TO BE COMPLETED BY APPLICANT
PRINT NAME (First, Middle, Last)                                                        OTHER NAME(S) USED



SOCIAL SECURITY NUMBER                                        DATE OF BIRTH (mm/dd/yy)              PLACE OF BIRTH (City/State or City/County)



HEIGHT                              WEIGHT                              HAIR COLOR                          EYE COLOR                      SEX



ORGANIZATION
    ACF         AoA          OS          OIG           AHRQ         SAMHSA             PSC            CDC         NIH        IHS       CMS        Other

BUILDING / ADDRESS                                                                                         ROOM NUMBER             TELEPHONE
HOME

                                                                                                           EMAIL Address


                                                          TO BE COMPLETED BY AUTHORIZING OFFICIAL
POSITION SENSITIVITY                                SPECIAL DOOR ACCESS REQUIRED
     Level 1       Level 2          Level 3
     Level 4       Level 5          Level 6
TYPE OF APPOINTMENT (check one) NOTE: If you check "Stay in School", "Fellow", "Intern", or "Temporary", you must type in the "Not to Exceed Date".
                                                                                                                        Not to Exceed Date (mm/dd/yy)
          Permanent / NTE                Stay in School           Fellow           Intern             Temporary

AUTHORIZING OFFICIAL NAME                                                                                                          TELEPHONE



BUILDING                                                          ROOM NUMBER               E-MAIL ADDRESS



AUTHORIZING OFFICIAL SIGNATURE                                                                                                                   DATE (mm/dd/yy)




                                                     TO BE COMPLETED BY PSC PERSONNEL SECURITY OFFICE
INVESTIGATION TYPE
     NAC           NACI              NACIC              NACLC              ANACI            CNACI            BI         SSBI         MBI          LBI                SAC

     Other (state type)
DATE INVESTIGATION COMPLETED                  IDENTIFICATION VERIFIED                   LEVEL OF POSITION                            BADGE EXPIRATION DATE
(mm/dd/yy)                                              Yes        No                                                                (mm/dd/yyyy)
                                                                                            Level
BADGE TYPE                                                      SECURITY OFFICER'S TELEPHONE                            VERIFYING SECURITY OFFICER
    Temp NTE 6 Months             Permanent (5 Years)

    Permanent NTE
                                  Date (mm/dd/yy)

                                                              TO BE COMPLETED BY PSC ISSUING OFFICE
IDENTIFICATION VERIFIED                                       DATE BADGE ISSUED (mm/dd/yy)                              BADGE EXPIRATION DATE (mm/dd/yyyy)
            Yes       No

BADGE ISSUING OFFICIAL (Signature)                                                                                                               DATE (mm/dd/yy)




PSC-29 (9/06)                                                                                                                                           PSC Graphics: (301) 443-1090 EF
                               PRIVACY ACT STATEMENT

This information is provided pursuant to 5 U.S.C. 552a (Privacy Act of 1974) for individuals
supplying information for inclusion in a system of records. E.O. 9397 and 31 U.S.C.
7701(c) (2) authorize the collection of the SSN. The collection of your SSN is mandatory to
identify and authenticate that a person is who they claim to be other than by a name. An
identifier is essential in selecting a record and determining that a record pertains to a
particular individual from a set of records. Information you provided will be used to identify
records properly associated with your application. The primary use of the information is by
PSC Administrative Operations Service staff to: issue Identification Badges and perform
background investigations for Federal Employees and Contractors as described by HSPD-
12 and FIPS-201 supported by the PSC for the Parklawn Building complex and other HHS
Facilities. Information from these records may be disclosed outside the Department as
follows: to appropriate federal, state or local agencies responsible for investigating,
prosecuting, enforcing, or implementing statutes, rules, regulations or orders when HHS
becomes aware of evidence of a potential violation of civil or criminal law; to a
congressional office from the record of an individual in response to a verified inquiry from
that congressional office made at the written request of that individual; to the Department
of Justice (DOJ) where DOJ has agreed to represent the federal government, HHS or
employees of HHS in case of lawsuit; to a contractor when HHS contracts with a private
firm for the purpose of collating, analyzing, aggregating, or otherwise refining records in
this system; to officials of labor organizations recognized under 5 U.S.C. Chapter 71 when
relevant and necessary to their duties of exclusive representation, concerning personnel
policies, practices, and matters affecting working conditions; to organizations deemed
qualified by the Secretary to carry out quality assessments or utilization review; and HHS
may disclose statistical reports containing information from this system of records to city,
county, state, and federal government agencies (including the Government Accountability
Office). Furnishing the information on this form is entirely voluntary; however, failure to do
so will prevent the conduct of a background investigation and result in the non-issuance of
identification badge.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:18
posted:11/24/2011
language:English
pages:2