DSS Commercial and Government Entity (CAGE) Code Request for Information

DSS CAGE Code Information Collection

Initial Information Collection

Instructions: The Defense Security Service (DSS) Directorate for Industrial Security Field Operations (ISFO) requests that Facility Security Officers (FSO) provide the following information about your company’s facility. DSS will use this information to better manage the National Industrial Security Program (NISP). You will be asked to provide UNCLASSIFIED information about your facility’s number of employee clearances, contract programs with active DD254s, Information Security (IS), storage and holdings. Please be prepared to provide the information referenced on the form and have supporting documentation available for review. Information provided by the responding contractors will be handled by DSS as “For Official Use Only,” sensitive commercial information. If you have any questions, please contact the Quality Assurance Team Chief:

Name:	Micah Komp
Agency:	Defense Security Service
Address:	Russell-Knox Building
	27130 Telegraph Road,
	Quantico, VA 22134-2253
Phone:	(571) 305-6632
Email:	Micah.Komp@dss.mil

Your assistance is greatly appreciated!

Privacy Act Statement

AUTHORITY: The legal authority for DSS to collect DoD Contractor data is addressed in 5 U.S.C. 301, Departmental Directives and Instructions; E.O. 12829, National Security Program; E.O. 13526, Classified National Security Information; DoD 5220.22-M, National Industrial Security Program; DoD 5220.22-R, Industrial Security Regulation; 50 U.S.C. National Security Act of 1974, as amended; DoD Directive 5105.42, Defense Security Service.

PURPOSE: Information collected on this database will be used to research, review, verify and track cleared companies/facilities operating under the NISP.

ROUTINE USES: In addition to those disclosures generally permitted within DoD or outside DoD under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the records contained in this system may specifically be disclosed outside DoD as a routine use pursuant to 5 U.S.C. a(b)(3) as follows: DoD Blanket Routine Uses, to DSS Insider Threat Identification and Mitigation Program personnel or other DoD/Federal law enforcement authorities for use in assessing a potential risk and/or threat to DSS/DoD personnel, property, and information that could result in loss or degradation of DSS, DoD or other Federal Government resources or capabilities.

DISCLOSURE: The information disclosed by you on this database is voluntary; however, failure to provide the requested information will impede, delay or prevent further processing.

AGENCY DISCLOSURE STATEMENT

The public reporting burden for this collection of information is estimated to average 20 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 other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

OMB Control Number: 0704-XXXX

Expiration Date: xx/xx/xxxx

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM

I. FACILITY

Please provide the following information for your facility.

Facility Name:

DBA or TA:

Address 1:

Address 2:

City:

State:

Zip:

Phone Number:

Company Website address Address:

Type of Business (Select one that closest describes your facility)

Accounting Alarm (Central Station) Alternate Storage Facility Architectural Building Management CRAF Program College/University Commercial Carrier Construction Consulting Courier Service Custodial Services Design & Manufacturing Engineering Explosives/Ordnance Freight Forwarder Graphic Arts/Video/Digital Productions Guard/Security Services Holding Company

Information Systems & Services Law Firm Manufacturing Marketing/Liaison Patent Attorney Manufacturing Professional Association Professional Employer Organization (PEO) Professional Services Research & Development Sealift Programs Services Shipbuilding, Maintenance & Repair Software Engineering Telecommunications Temporary Help Supplier Translation Services Transportation Verbatim Reporting Other (Please explain below)

Principal Products/Services:

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS RFI

II. Legal Structure
Organization Type (Select One):		Corporation, LLC, Sole Proprietorship, Partnership, University/College, or Joint Venture, or Other
If part of a corporation, please select businesses’ position in the corporation:			Parent, Division, Branch, Subsidiary, etc.
If a Division or Subsidiary, please provide the following information for the Home Office or Parent Organization:
Name:
CAGE Code:
If a Joint Venture, please list the Joint Venture partners:
Name:
CAGE Code:

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS RFI

III. Facility Security Officer and Senior Management Official
Please provide the following information for your Facility Security Officer (FSO).
Name:					Appointment Date:	MM/DD/YYYY
Office Phone:			Alt. Phone (Business Cell):
Fax:			Email:
If applicable, please provide the following information for your Assistant Facility Security Officer (AFSO).
Name:
Office Phone:			Alt. Phone (Business Cell):
Fax:			Email:
Please provide the following information for your Senior Management Official (See the Facility KMP List).
Name:
Office Phone:			Fax:
Email:

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM

IV. Employee Clearance Information
Please provide counts for each category as of the date this form is completed. Include all part-time employees.	Top Secret	Secret	Confidential	Uncleared
Total count of employees and consultants:
Employees Assigned Overseas:
Consultants (excluding subcontractors):
Employees with Limited Access Authorizations (LAA):
Employees identified to DSS as Key Management Personnel: :
Foreign Nationals on Extended Visits or Assignment to the Cleared Facility (see NISPOM para. 10-508):
Employees located at off-site or uncleared locations:
Please provide any additional remarks about Employee Clearances:
Please identify all programs being worked on by foreign nationals (persons who are not citizens or nationals of the United States):
Does this facility sponsor cleared Student Interns or Summer Students? Yes No
Did this facility sponsor tradeshows, conferences, or external learning events during the past year ?		Yes No
Please identify the topic or program area for the tradeshow, conferences or external learning events sponsored by this facility:
Please provide the total number of international visits this cleared facility received in the past 12 months._______

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM

V. Contracts/Programs
Please provide a count of all contracts with DD254s/classified contracts pertaining to this CAGE code. Please note: The total number of contracts you provide in response to this question will be used to determine what additional sections of this survey you will be asked to complete. Please ensure that the total number of contracts you provide is an accurate total of classified contracts for your facility.
Total number of DD254s/classified contracts:
Please provide the following information for each DD254/Classified Contract associated with this facility.
Contract Number:
Program Name:				Classification Level:		Confidential, Secret, Top Secret
Government Activity (GA):
GA Program Office:
GA Point of Contact (POC):
GA POC Email:				GA POC Phone:
Note: Government Activity Point of Contact, Email, and Phone are optional.
Is this facility the prime contractor?					Yes No
Are there any subcontractors working on this contract?					Yes No
Total number of subcontractors:
Please provide the CAGE code for each subcontractor DD254 sponsored by your facility working on the specified contract.
CAGE Code:

V. Contracts/Programs
Please identify all Industrial Base Technology categories for all DD254s pertaining to this Cage Code.
	C4ISR Command, control, communication, and computers Software Lasers Optics Sensors (Acoustic) Radars Electronics Armament and Self Protection Armament and Survivability Directed Energy Manufacturing Equipment and Processes Signature Control Lasers Airframe and Propulsion Aeronautics Systems Manufacturing Equipment and Processes Energy Systems Vehicle and Propulsion Ground Systems Manufacturing Equipment and Processes Energy Systems	Vessel and Propulsion Marine Systems Manufacturing Equipment and Processes Energy Systems Nuclear Avionics Positioning, Navigation, and Time Electronics Software Test and Evaluation Software Electronics Manufacturing Equipment and Processes Other Biological Chemical Raw Materials Agricultural Medical Nanotechnology Synthetic Biology Energetic Systems Quantum Systems Computational Modeling of Human Behavior Cognitive Neuroscience Other

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM

.VI. Classified Holdings/Storage

Does this facility have safeguarding? Yes No [Go to Section VII] fied

Please provide your mailing address for classified mail.

Address 1:

Address 2:

City:

State:

Zip:

Please provide the following counts:

Top Secret

Secret

Confidential

Total number of classified items (to include computer media) currently on hand: Ensure that you have a current contract (DD254) or written retention authority that supports retention If your facility does not keep a count of the number of secret and confidential items being stored, please provide an estimate. If you cannot provide an estimate, please indicate “unknown”

Classified Hardware (e.g. Large classified items or items with embedded classified components that do not fit in an approved container) If your facility does not keep a count of the number of secret and confidential items being stored, please provide an estimate. If you cannot provide an estimate, please indicate “unknown”

Number of GSA-approved security containers used for storing classified materials (Facilities should no longer be using non-GSA approved containers (see NISPOM paragraph 5-303):

Closed Areas with IDS meeting NISPOM Standards:

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM

Do you have any Protective Distribution Systems (PDS)?

Yes No

Do you use any supplemental protection for classified information (i.e. IDS, security guards)?

Yes No

If so, please list any supplemental protections:

VII. Communications Security (COMSEC)
Does your facility have any Communication Security (COMSEC) materials?						Yes No
If so, please provide the following information on COMSEC at your facility.
COMSEC Custodian:
Type of Account:
Account Number:
Number of items on hand:				Date of last NSA audit:			MM/DD/YYYY
Next transaction number:
VIII. Special Considerations:
Does your facility have NATO briefing requirements?						Yes No
Does your facility have COMSEC briefing requirements?						Yes No
Does your facility have CNWDI briefing requirements?						Yes No
Is DCMA onsite?						Yes No
If DCMA is onsite, please provide the following information:
DCMA Name:
Phone:			Email:
Has this facility engaged in any direct or commercial military sales to foreign countries?								Yes No
If so, Please list the foreign countries receiving direct or commercial military sales:

FOR UNCLASSIFIED INFORMATION ONLY! DO NOT ENTER ANY CLASSIFIED INFORMATION ANYWHERE ON THIS FORM