Domestic Guest Researchers

General Information for Domestic Guest Researchers
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)					          	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: A phone number must be provided for the contact.
Last Name			First Name
     			     
Phone Number	     

Information for Domestic Guest Researchers
Employer/Home Organization Contact
Last Name			First Name					Phone Number
     			     					     
Education Information
Guide: The street address of the educational institution is not mandatory. City and state are required for NIST Associates only if the country is U.S. Tip: The correct format for entering dates attended is "MM/01/YYYY." An exact day of the month is not required.
Educational Institution – I
School Name	     
Street Address	     
Address Line 2	     
Address Line 3	     
City	     			State				  
County/Province	     			Country	     			Zip	     
Subjects Studied		     
Dates Attended		From					To
		     					     
Highest Degree(s) Awarded		     
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 5