Other NIST Associates

General Information for NIST Associates
Personal Information
Last Name	First Name		Middle Name			Suffix (Jr. III etc.)
     	     		     			     
Home Address
Street	     		City			     
County/Province	     		State			     
Country	     		Zip/Postal Code			     
Place of Birth
City	     		State			  
County/Province	     		Country			     
Citizenship	     		Gender			     
Date of Birth (MM/DD/YYYY)			     
Passport Number (foreign NIST Associates)			     		SSN		     
Mother’s Maiden Name			     
Emeritus Status (Y/N)			     
Employed by Another Federal Agency (Y/N)			     
Other Names Used And Dates When Used
Guide: Give other names you used and the period of time you used them (for example: your maiden name, name[s] by a former marriage, former name[s], alias[es], or nickname[s]). If the other name is your maiden name, put "nee" in front of it. Only required for security forms.
Last Name		First Name		Middle Name
     		     		     
Dates Used		From		To
		     		     
Last Name		First Name		Middle Name
     		     		     
Dates Used		From		To
		     		     
Last Name		First Name		Middle Name
     		     		     
Dates Used		From		To
		     		     
Contact Information for NIST Associate (prior to arrival)
Guide: An e-mail address is required for security processing in e-QIP (Electronic Questionnaires for Investigations Processing).
E-mail Address:      

Employer/Home Organization
Guide: The NIST associate's employer or home organization can be one of the following: (1) the associate's employer, (2) the educational institution (university or college) that the associate attends when not working at NIST, (3) a business owned by the associate, or (4) "SELF" if associate is self-employed or a retiree, and not associated with any incorporated business. Street address is mandatory for all guest researchers. City, state, and zip code are required for NIST Associates only if the country is U.S. The second line of street address cannot be used for foreign guest researchers.
Organization Name	     
Street Address	     
Address Line 2	     
Address Line 3	     
City	     	State		  
County/Province	     	Country	     	Zip	     
Sponsor Information
Guide: The sponsor can be one of the following: (1) employer/home organization, (2) an organization that has signed a CRADA or IPA agreement with NIST, (3) "SELF" for associates who are retirees or self-employed and not associated with any incorporated business, or (4) other organization that sponsors the NIST Associate. Street address is mandatory for all guest researchers. City, state, and zip code are required for NIST Associates only if the country is U.S. The second line of street address cannot be used for foreign guest researchers.
Sponsor Name	     
Street Address	     
Address Line 2	     
Address Line 3	     
City	     	State		  
County/Province	     	Country	     	Zip	     

Emergency Personal Contact
Guide: The emergency personal contact information is mandatory for all NIST associates, except off-site collaborators. A phone number must be provided for the contact.
Last Name			First Name
     			     
Phone Number	     
Information for NIST Associates
Guide: If the NIST Associate is at NIST pursuant to an agreement between NIST and another organization or a sole proprietor, enter type of agreement and, if known, enter the agreement number. A CRADA number is mandatory for research associates (RA). Agreement type and agreement number should be provided for facility users.
Agreement Type		     
Agreement Number		     
Security
Has the United States Government ever investigated your background and/or granted a security clearance?				      Yes       No
If Yes, provide Agency Security Officer name & phone number.				     
Have you worked at NIST in the past?				      Yes       No

This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of Management and Budget (OMB). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the PRA unless that collection of information displays a currently valid OMB control number. Public reporting burden for this collection is estimated to be 30 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 or any aspect of this collection of information, including suggestions for reducing this burden, to the National Institute of Standards and Technology, Attn: XXAdd-Individual-Point-of-Contact_InformationXX.

OMB Control No. 0693-XXXX

Expiration Date: XX-XX-XXXX

NIST Associate General Questionnaire 4