Form 10-152 Background Clearance Initiation Request

NPS Form 10-152 (Rev. 09/2016) OMB Control No. 1024-####

National Park Service Expiration Date XX/XX/XXXX

BACKGROUND CLEARANCE INITIATION REQUEST

Applicants for Federal Employment and Proposed

Contractors/Partners/Non-Federal Personnel

INSTRUCTIONS: All applicants are required to complete Section I. Non-Federal applicants, to include proposed contractors, partners, and cooperators, must also complete Section III below and attach a completed Form OF-306, “Declaration for Federal Employment.” Completed forms should be submitted to the HR office who provided the form to you, your agency sponsor, or your Contracting Officer’s Representative.

SECTION I – To be Completed by Applicant/Proposed Contractor

Category of Applicant:

Applicant for Federal Employment Contractor/Partner/Non-Federal Personnel * *Must also complete Section III below and attach completed OF-306 (Declaration for Federal Employment)

Applicant Full Name (Must Match Documents)

Last

First

Middle ( NMN)

Suffix

     

     

     

     

Social Security Number

Date of Birth

Place of Birth

Country of Citizenship ( US)

     

     

     

     

Contact Telephone Number

Email Address

     

     

Home Street Address

City

State

Zip Code

     

     

     

     

Have you ever had a HSPD-12 background clearance initiated by another FEDERAL AGENCY? Yes No If “Yes”, please provide the following:

Name of Agency

Approximate Date of Investigation

     

     

The applicant by his or her signature certifies that all the information given is complete and correct, and that no false or misleading information or false statements have been given.

Signature of Applicant

Date

     

SECTION II – To be Completed by Agency Sponsor/Requestor Only

Name of Agency Sponsor/Requestor

Organization (Directorate/Division/Office)

Office Phone Number

     

     

     

Organization (Directorate/Division /Office/Region/Park)

Organizational Code

     

     

Account Number (for Background Investigation Charges)

Type of Background Investigation Requested

     

NACI Other:      

SECTION III – Additional Information Required for Proposed Contractors/Partners/Non-Federal Personnel

Company Employing Proposed Contractor/Partner/Non-Federal Personnel

Contract/Agreement Period of Performance (POP)

     

Start      

End      

Contract/Agreement Number

Completed Form OF-306 attached

     

Signature of Agency Sponsor/Requestor

Date

     

NOTICES

Privacy Act Statement

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this form.

Authority: The authority to collect information on the attached form is derived from one or more of the following:

Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301; sections 8(b), 8(c), and 9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22, United States Code, sections 1434 and 2585.

Purposes and Uses: The collection, maintenance, and disclosure of background investigative information are governed by the Privacy Act. This information is being collected for the purpose of conducting a suitability background investigation, and the information will be protected from unauthorized disclosure. In line with new regulations mandated by the U.S. Office of Personnel Management Investigative Services and the Department of the Interior (DOI), the National Park Service (NPS) Personnel Security Branch is utilizing the Electronic Questionnaires for Investigations Processing (E-QIP) System. As a result, electronic submission of the standard form 85, for suitability background investigations (NACI) or the Standard Form 85P, for Public Trust, is now required. The DOI and NPS requires all Federal employees and non-Federal personnel requiring access to NPS property and/or receive a DOIAccess badge to be processed for a suitability background investigation, in accordance with Executive Order 10450 and the Homeland Security Presidential Directive (HSPD-12). The Department of the Interior and the National Park Service requesting the background investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. Information from the contractor may be transferred to appropriate Federal, State, local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.

Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Special Use Permit

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Applicants are required to provide their social security or taxpayer identification number for activities subject to collection of fees and charges by the National Park Service (31 U.S.C. 7701). Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the initiation of your background clearance and subsequently, your approval to be granted physical and/or electronic access to NPS offices and computer systems. The authority for soliciting and verifying your SSN is Executive Order 9397. The information gathered through the use of the SSN will be used only as necessary for processing this application and will be carried out in accordance with established regulations and published notices of system of records.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the National Park Service with the information needed to initiate a background clearance. All applicable parts of the form must be completed in order for your request to be considered. You are not required to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 7 minutes per response including the time it takes to read, gather and maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your completed form to this address.

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Management and Accountability, (Item 10D) (N1-79-08-9))