Form TSA Form 2211 TSA Form 2211 SSI Access Threat Assessment Questionnaire

SSI Access Threat Assessment Questionnaire

SSI Access Threat Assessment Questionnaire

INSTRUCTIONS: Please print or type the required information requested below for consideration of your TSA sensitive security information (SSI) access request. Please bring the completed form with you when you submit your fingerprints, location to be determined by TSA. Complete Section 3 by selecting the appropriate responses and providing any required additional details on a separate page for submission with your completed access questionnaire. Please reference the corresponding number for the Section 3 question that you are addressing by marking your response with that number.

SECTION 1 – CONTACT INFORMATION

     

Full Legal Name (Last, First, Middle)

     

Aliases and/or Prior Names, if any

     

Name of Employer

     

Work Address (Street, City, State, Zip Code)

     

Mailing Address (Street, City, State, Zip Code), if different from Work Address

     

Email Address, if email correspondence is preferred

SECTION 2 – PERSONAL INFORMATION
     								     
Residential Address (Street, City, State, Zip Code), if different from Mailing Address.								Residential Phone No.
Male Female		   -    -     		     				    -    -     
Gender		Date of Birth (mmddyyyy)		Place of Birth (Country)				Social Security No. (voluntary)
     		     				     
Country of Citizenship		Alien Registration No., if applicable				Non-Immigrant Visa No., if applicable
     
Passport Country and No.: This information is voluntary and may expedite the adjudication process for applicants who are U.S. citizens born abroad.

SECTION 3 – ADDITIONAL QUESTIONS

Attorney Applicants Only:

1. Yes No Are you, and have you always been, in good standing with every bar to which you are, or have been, a member? If ‘No’, please provide a detailed explanation on a separate piece of paper.

2. Yes No Have you ever been denied admission to any bar? If ‘Yes’, please provide a detailed explanation on a separate piece of paper.

3. Yes No Have you ever been disciplined, admonished, suspended, disbarred or otherwise sanctioned by or from any bar of which you are, or have been, a member? If ‘Yes’, please describe on a separate piece of paper each such incident, even if the sanction later was withdrawn, suspended or modified.

4. Yes No Has any person or entity, while represented by you, ever been held in contempt for violating a confidentiality or protective order in a judicial or administrative proceeding? If ‘Yes’, please describe on a separate piece of paper each such incident, even if the citation later was withdrawn, suspended or modified.

5. Yes No Has any person or entity, while represented by you, ever been sanctioned as a result of conduct related to a judicial or administrative proceeding? If ‘Yes’, please describe on a separate piece of paper each such incident, even if the sanction later was withdrawn, suspended or modified.

Court Reporter Applicants Only:

6. Yes No Are you currently listed on the registry of the National Court Reporters Association, or have you passed an equivalent qualifying examination? If ‘Yes’, please specify the registri(es) on a separate piece of paper.

7. Yes No Do you currently hold a clearance for access to classified national security information under Executive Order No. 12958? If ‘Yes’, please specify on a separate piece of paper the level of the clearance and the agency that granted it.

8. Yes No Have you ever been denied any type of security-related clearance with the Federal government? If ‘Yes’, please provide a detailed explanation on a separate piece of paper.

9. Yes No Have you ever been disciplined or terminated for the mishandling of information? If ‘Yes’, please provide a detailed explanation on a separate piece of paper.

All Applicants:

10. Yes No Have you ever been held in contempt for violating a confidentiality or protective order in a judicial or administrative proceeding? If ‘Yes’, please describe on a separate piece of paper each such incident, even if the citation later was withdrawn, suspended or modified.
    
    

11. Yes No Have you ever been sanctioned as a result of conduct related to a judicial or administrative proceeding? If ‘Yes’, please describe on a separate piece of paper each such incident, even if the sanction later was withdrawn, suspended or modified.

12. Yes No Do you agree to abide by the TSA instructions concerning the handling of SSI in connection with this proceeding in the absence of any contrary ruling by the Court?

Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.

Executed on: ________________ Signature: ___________________

Should I seek judicial review of TSA’s final decision on my threat assessment, I authorize TSA to release the foregoing and any other information related to my threat assessment to the court(s) presiding over that review.

Executed on: ________________ Signature: ___________________

PRIVACY ACT NOTICE: Authority: 49 U.S.C. §114 authorizes the collection of this information. Purpose: TSA will use this information to conduct a threat assessment on individuals who seek access to Sensitive Security Information (SSI) for use in a civil proceeding in federal court. Routine Uses: The information will be used by and disclosed to DHS personnel and contractors or other agents who need the information to assist in activities related to transportation security. Additionally, DHS may share the information with law enforcement, intelligence, or other government agencies as necessary to identify and respond to potential or actual threats to transportation security, or pursuant to its published Privacy Act system of records notice (SORN), DHS/TSA 002, Transportation Security Threat Assessment System (T-STAS). This SORN was last published in the Federal Register on November 8, 2005, and can be found at 70 FR 67731- 67735. Disclosure: Furnishing this information is voluntary. However, failure to furnish the requested information may delay or prevent the completion of your security threat assessment, without which you may not be granted access to SSI. Providing your Social Security Number is voluntary, but failure to provide it may result in a delay in processing your threat assessment.

Paperwork Reduction Act Statement of Public Burden: TSA is collecting this information to conduct a threat assessment to determine your eligibility to gain access to Sensitive Security Information (SSI) for use in connection with a federal civil court proceeding.  This is a voluntary collection of information, but failure to provide the information may result in an inability to approve your eligibility to gain access to SSI for use in connection with a federal civil court proceeding. TSA estimates that the total average burden per response associated with this collection is approximately one hour. If you have any comments regarding this form, you may write to TSA, Office of Chief Counsel, TSA-2, 601 S. 12th Street, Arlington, VA, 22202. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it

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TSA Form 2211, December 2006 OMB control number 1652-0042; expiration date 10/31/2010