Draft Form

PRIVACY ACT STATEMENT: The information collected on this form is necessary to meet identify proofing requirements of Homeland Security Presidential Director (HSPD)-12. The information is used to verify the personal identify of VA Employees, contractors, and affiliates (such as student, WOC employees, and others) prior to issuing a Department identification credential. The identification credential is required for the use of VA physical and digital access control systems. The collected information is protected in accordance with the Privacy Act of 1974, 5 USC Section 552(3) and maintained under the authority of 38 USC Section 501 and 3 USC Sections 901-905.

RESPONDENT BURDEN: Public reporting for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing this burden, to the VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, D.C. 20420. Do NOT send requests for benefits to this address.