General Information for NIST Associates

OMB Control No. 0693-0067

Expiration Date: 08/31/2019

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			     
Employed by Another U.S. 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	     
Work Permit Number (Required if under 18) Only for Maryland Work Locations		     
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	     
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

PURPOSE

The National Institute of Standards and Technology (NIST) allows access to its campuses and resources for non-NIST employees for the purposes of furthering the NIST mission. These NIST Associates (NAs) include guest researchers, research associates, contractors, and other non-NIST employees. The information collected through this instrument will be input into the NIST Associates Information System (NAIS) and sent to the appropriate personnel for approval processing and to allow the NA preliminary access to the NIST campuses and resources. The information collected may also be the basis for further security investigations, as necessary.

AUTHORIZATION AND RELEASE
I hereby authorize the NIST and other authorized federal agencies to obtain any information required from the Federal government and/or state sources, including but not limited to, the Federal Bureau of Investigation (FBI), the Office of Personnel Management (OPM), the Defense Security Service (DSS), and from the State Criminal History Repository for states where I have resided and worked. This authorization is valid for two (2) years from the date signed or upon termination of my affiliation with NIST, whichever is earliest.

I understand that, pursuant to the Privacy Act, the information collected will be confidential, and disclosure limited to purposes authorized under the Privacy Act to conduct my background investigation. I understand that I may request a copy of such records as may be available to me under law.

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
Solicitation of information contained herein may be used as a basis for access determinations and is authorized by Executive Order 10450 and/or Section 231 of the Crime Control Act of 1990. Your Social Security number is being requested pursuant to Executive Order 9397. Disclosure of the information by you is voluntary. Failure to provide information requested on this form may result in the government’s inability make a favorable access determination.

PRIVACY ACT ROUTINE USES

Disclosure of this information is also subject to all the published routine uses as identified in the Privacy Act System of Records Notices:  NIST-1: NIST Associates. 

1. In the event that a system or records maintained by the Department to carry out its functions indicates a violation or potential violation of law or contract, whether civil, criminal or regulatory in nature, and whether arising by general statute or particular program statute or contract, or rule, regulation, or order issued pursuant thereto, or the necessity to protect an interest of the Department, the relevant records in the system of records may be referred, as a routine use, to the appropriate agency, whether Federal, state, local or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute or contract, or rule, regulation or order issued pursuant thereto, or protecting the interest of the Department.

2. To a Federal, state or local agency maintaining civil, criminal or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a Department decision concerning the assignment, hiring or retention of an individual, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other benefit.

3. To a Federal, state, local, or international agency, in response to its request, in connection with the assignment, hiring or retention of an individual, the issuance of a security clearance, the reporting of an investigation of an individual, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency’s decision on the matter.

4. In the course of presenting evidence to a court, magistrate or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations.

5. To a Member of Congress submitting a request involving an individual when the individual has requested assistance from the Member with respect to the subject matter of the record.

6. A record which contains medical information may be disclosed to the medical advisor of any individual submitting a request for access to the record under the Act and 15 CFR Part 4b if, in the sole judgment of the Department, disclosure could have an adverse effect upon the individual, under the provision of 5 U.S.C. 552a(f)(3) and implementing regulations as 15 CFR 4b.6.

7. To the Office of Management and Budget in connection with the review of private relief legislation as set forth in OMB Circular No. A-19 at any stage of the legislative coordination and clearance process as set forth in that Circular.

8. To the Department of Justice in connection with determining whether disclosure thereof is required by the Freedom of Information Act (5 U.S.C. 552).

9. To a contractor of the Department having need for the information in the performance of the contract, but not operating a system of records within the meaning of 5 U.S.C. 552a(m).

10. To the Administrator, General Services, or his designee, during an inspection of records conducted by GSA as part of that agency’s responsibility to recommend improvements in records management practices and programs, under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall be made in accordance with the GSA regulations governing inspection of records for this purpose, and any other relevant (I.e. GSA or Commerce) directive. Such disclosure shall not be used to make determinations about individuals.

11. Facilitate the processing and approval of NAs.

12. Facilitate tracking of NAs throughout their tenure at NIST.

13. Support processing of security-related documents and issuing of badges by DOC/NIST Security Office.

14. Provide aggregate statistical data for NIST budgeting, management, and planning.

15. Facilitate stipend and travel payments to foreign guest researchers.

16. Support processing of visas and other Immigration and Naturalization Service actions for foreign NAs.

17. Generation of reports in response to queries from NIST, DOC, Congress, and other external parties as may be required from time to time.

DISCLOSURE

When you submit the form, you are indicating your voluntary consent for NIST to use of the information you submit for the purpose stated.

PUBLIC REPORTING BURDEN STATEMENT
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: Personnel Security Requirements Division (CPR), General Services Administration, Washington DC 20405.

AUTHORIZATION AND RELEASE AND CERTIFICATION
BEFORE SIGNING THIS FORM, REVIEW CAREFULLY TO ENSURE THAT YOU HAVE PROVIDED ALL REQUESTED INFORMATION FULLY AND CORRECTLY. KNOWN AND WILLING FALSE STATEMENTS ARE PUNISHABLE BY LAW.
I declare under penalty of perjury that the statements made by me on this form are true, complete and correct.	SIGNATURE	DATE

NIST Associate General Questionnaire 5