Form MS 611B MS 611B PC Intelligence Background Questionnaire

OMB No. 0420-xxxx
Expiration Date: xx/xx/20xx

Peace Corps
Intelligence Background Questionnaire
Your application (or your relative’s application) discloses a possible connection between
your background and the Intelligence community. Any semblance of a connection
between the intelligence community at the federal, state or local level and Peace Corps
employees or Volunteers could seriously compromise the ability of the Peace Corps to
develop and maintain trust and confidence in our host countries.
The purpose of this form is to determine whether your intelligence connection would
compromise Peace Corps’ total separation from intelligence activities both in reality and
in appearance. 22 CFR § 305.2(e) and 22 USC § 2504(a). We require this form of any
applicant who has engaged in intelligence activities or been employed by an intelligence
agency, OR who has an immediate family member (i.e., parent, child, sibling or spouse)
who is or has been so engaged or employed.
If you have ever worked for the CIA, you are not eligible for Volunteer service or
employment at the Peace Corps and you should not fill out this form.
If you have any other type of possible intelligence connection, your application will
not be considered until you submit this form.
The person who works or has worked in intelligence should complete this form. If
the applicant’s immediate family member works or has worked in intelligence, the
immediate family member should complete the form, not the applicant. Usually relying
on memory is sufficient to answer most if not all of the questions.
If you have an immediate family member who works or has worked for the CIA,
you should not give them this form to complete. Please contact your relative in
person, not by phone, email, social networking, or any other means that is not in
person, and ask him or her to contact the Office of General Counsel at the CIA.
If your intelligence connection involves the National Security Agency, you (or, if
the connection is with a family member, that person) must contact NSA’s Office of the
General Counsel at 410-854-3910 before submitting this form to Peace Corps.
Burden Statement:
Public reporting burden for this collection of information is estimated to average 10 minutes. This estimate includes
the time for reviewing instructions and completing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
th
information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20 Street, NW,
Washington, DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.

After we review this form, we may find you fully eligible for service, we may bar you from
service for a specific time period, or we may limit your service to certain parts of the
world. If serious doubts exist about an applicant's intelligence connection, the issue will
be resolved in favor of exclusion from service.
If you disagree with the eligibility decision, you may appeal to the Director of the Peace
Corps. You may fax your appeal to 202-692-2101.
If you have any questions about this form, please contact the Peace Corps Office of the
General Counsel at 202-692-2150.

Definitions:
"Intelligence activity" includes any activities or specialized training involving or related
to the clandestine collection of information, or the analysis or dissemination of such
information, intended for use by the United States government in formulating or
implementing political or military policy in regard to other countries. The term
"intelligence activity" includes any involvement in covert actions designed to influence
events in foreign countries.
“Intelligence agency” means an agency or division of an agency a substantial part of
whose mission includes intelligence activities.
"Employment," "employee" or "employed" refer to the existence of a relationship of
employer and employee, whether full-time or part-time, permanent or temporary, without
regard to the length of time the relationship existed or is proposed to exist, and includes
for purposes of this policy individuals performing duties as volunteers, fellows, interns,
consultants and personal service contractors.
“Agency” means any state, county, municipal, or federal agency.
Disclosure of this information may be prohibited by law. If so, it may be necessary for
you to consult the Office of the General Counsel of the agency involved before
responding. The agency involved should advise whether or not the facts requested
may be disclosed. The agency may elect to discuss these issues with the Office of
the General Counsel at the Peace Corps to expedite a decision.
If disclosure is prohibited, please contact the Office of the General Counsel at the
Peace Corps to discuss your particular case to the extent you can do so. The
Peace Corps will consult with the agency involved in order to determine how to
proceed.

A copy of the Peace Corps policy, the language of which will govern the final decision,
is available upon request. If you have any questions, please call this office at (202) 692-

2150. If you are authorized to provide information, or if the work was of a nature that
does not require authorization, please forward it to:
Office of the General Counsel
1111 20th Street, NW, Suite 8200
Washington, DC 20526
A decision regarding your eligibility, based on the information you provide, will be made
as soon as possible.

Please be as specific as you can when you respond to the following questions.
Unless otherwise indicated, please answer all questions.
1.

Are you the applicant? (If the answer is yes, skip to question 3)

2.
Are you the applicant’s relative? If so, how are you related to the applicant? Do
you currently live with the applicant and, if not, when was the last time you lived with the
applicant?

3.
Are you or were you previously employed by or contracted with an intelligence
agency? (If the answer is no, skip to question 9)

4.

Which intelligence agency are (or were) you employed by or contracted with?

5.

When were you first employed by or contracted with an intelligence agency?

6.

When were you last employed by or contracted with an intelligence agency?

7.

Where are (or were) you employed by or contracted with an intelligence agency?

8.
Was your employment by or contract with an intelligence agency known to the
public?

9.
Do you engage in, or have you previously engaged in, intelligence activities? (If
the answer is no, skip to question 17)

10.

When did you begin performing intelligence activities?

11.

When did you last perform intelligence activities?

12.

Where do you (or did you) perform intelligence activities?

13.

Did the activity involve contact with foreign nationals?

14.

What intelligence-related training did you receive, if any?

15.

What duties did you perform?

16.

Were your intelligence activities known to the public?

17.
Please include any additional information you think may be helpful for Peace
Corps to be aware of in reviewing the applicant’s application.