Form GSA 850 GSA 850 Contractor Information Worksheet

CONTRACTOR INFORMATION WORKSHEET

OMB Control Number: 3090-0283
Expiration Date: 7/31/2019

(For Official Use Only)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB)
control number. The OMB control number for this collection is 3090-0283. We estimate that it will take 15 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other
aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW,
Washington, DC 20405.

1. Contract Employee Information - To Be Completed By Contractor
Full Last Name(s) (Family)

Full First Name (Given)

Full Middle Name (or NMN if none) Suffix

Social Security Number Date of Birth Place of Birth (City) Place of Birth (Country)
Home Street Address

Place of Birth: U.S. State

Gender

Place of Birth: Mexico (State)/Canada (Province)

Street Address (Line 2)

City

Country

Phone Number (Work Cell)

U.S. State

Phone Number (Work Number)

Prior Investigation

Mexico (State)/Canada (Province)
Personal E-Mail Address

ZIP Code

Position (Job) Title

Approximate Investigation Date Agency Adjudicated Prior Investigation

U.S. Citizen

Non-U.S. Citizens Only: Complete the following:
U.S. Port of Entry City and State

Date of Entry Less than 3 Years U.S. Resident Alien Registration Number

Country of Citizenship

2. Contract Information - To be completed by GSA Requesting Official
Company Name (Primary)

Data Universal Numbering System (DUNS) Number

Company Name (Subcontractor) If applicable

Contract
Start Date

Task Order (TO)/Delivery Order (DO) Number
Contract Number Type
(Enter Contract Base Number if TO/DO is Not Applicable)

Contract
End Date

Has
Option Years

Number of Option
Years

Company Point of Contact
(POC) First Name

Company Point of Contact
(POC) Last Name

Point of Contact (POC) Phone Number
Point of Contact (POC) E-Mail Address
(Work Number)

Alternate Company Point
of Contact (POC) First Name

Alternate Company Point of Contact
(POC) Last Name

Alternate Point of Contact (POC)
Phone Number (Work Number)

Alternate Point of Contact (POC)
E-Mail Address

Alternate Company Point
of Contact (POC) First Name

Alternate Company Point of Contact
(POC) Last Name

Alternate Point of Contact (POC)
Phone Number (Work Number)

Alternate Point of Contact (POC)
E-Mail Address

Alternate Company Point
of Contact (POC) First Name

Alternate Company Point of Contact
(POC) Last Name

Alternate Point of Contact (POC)
Phone Number (Work Number)

Alternate Point of Contact (POC)
E-Mail Address

Alternate Company Point
of Contact (POC) First Name

Alternate Company Point of Contact
(POC) Last Name

Alternate Point of Contact (POC)
Phone Number (Work Number)

Alternate Point of Contact (POC)
E-Mail Address

3. Reimbursable Work Authorizations (RWA) / Interagency Agreement (IAA) (If applicable) - To be completed by GSA Requesting Official
RWA/IAA Number

Agency

4. Project/Work Location Information (Government site where contractor is working) - To be completed by GSA Requesting Official
GSA Building Number (Building Number Search)

Other

Contractor Type
(Definitions on Page 2)

Major Sponsoring Organization Sponsoring Office Symbol GSA Region

American Recovery and Reinvestment Act
(ARRA) Long Term Contractor

GENERAL SERVICES ADMINISTRATION

GSA 850 (REV. 6/2017)

5. Type of Investigation Requested - To be completed by GSA Requesting Official
Investigation Type Request
Note: National Security positions are processed by GSA Personnel Security (CIS)

Homeland Security Presidential Directive
(HSPD 12) Card Required?

6. GSA Requesting Official Information - To be completed by GSA Requesting Official
Last Name

First Name

Middle Name
or (NMN) if none

E-Mail Address

Work Phone Number

Is PM/COR/CO/
CS

Alternate Last Name

Alternate First Name

Middle Name or
(NMN) if none

Alternate E-Mail Address

Alternate Work
Phone Number

Is PM/COR/CO

Alternate Last Name

Alternate First Name

Middle Name or
(NMN) if none

Alternate E-Mail Address

Alternate Work
Phone Number

Is PM/COR/CO

Alternate Last Name

Alternate First Name

Middle Name or
(NMN) if none

Alternate E-Mail Address

Alternate Work
Phone Number

Is PM/COR/CO

Alternate Last Name

Alternate First Name

Middle Name or
(NMN) if none

Alternate E-Mail Address

Alternate Work
Phone Number

Is PM/COR/CO

INSTRUCTIONS
Applicability of Contractor Information Worksheet:
Use this Contractor Information Worksheet for all GSA contractors, located at http://www.gsa.gov/forms.
Contractor Type Definitions (Any GSA Service or Office May be Associated with Building Support, Embedded Contractors):
Building Support: Building maintenance or construction support contractor
Embedded: “Side-by-side” or white collar contractor providing business services, and may have staff-like access to GSA space and IT systems
External: Does not access GSA building or IT systems but requires a check or investigation
Child Care: Child care worker
GSA Region Options: Region 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, NCR (National Capital Region) (11), or CO (Central Office)
Transmitting the Contractor Information Worksheet:
Do not save completed forms on your workstation. Per GSA requirements:
If Personally Identifiable Information (PII) needs to be transmitted over the Internet, it must be sent using encryption methods defined in Chapter 5,
Paragraph 7 of GSA Order CIO P 2100.1E GSA Information Technology (IT).
All passwords must be encrypted in storage.
All sensitive information, such as PII, as deemed by the data owner, which is transmitted outside the GSA firewall, must be encrypted.
Certified encryption modules must be used in accordance with FIPS PUB 140-2, “Security requirements for Cryptographic Modules.”
When using password generated encryption keys, a password of at least 8 characters with a combination of letters, numbers, and special
characters is required. A password of at least 12 characters is recommended.
Systems implementing encryption must follow the key management procedures and processes documented in CIO IT Security Procedural
guide 09-43, “Key Management.”
If PII needs to be e-mailed within the GSA network, please use Google Mail. For additional protection the information also can be encrypted as
described in Chapter 5, Paragraph 7, of this IT security policy.
If PII needs to be sent by courier, printed, or faxed several steps should be taken. When sending PII by courier mark "signature required" when
sending documents. This creates a paper trail in the event items are misplaced or lost. Don't let PII documents sit on a printer where unauthorized
employees or contractors can have access to the information. When faxing information use a secure fax line. If one is not available, contact the office
prior to faxing so they know information is coming and contact them after transmission to ensure they received it. For each event the best course of
action is limit access of PII only to those individuals authorized to handle it, create a paper trail, and verify information reached its destination.
Submission Information:
Check with your GSA regional point of contact for instructions on how to submit the completed form.
Privacy Act Notice:
In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by the Federal Property and
Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; E.O. 9397. Disclosure of the information is voluntary. This form will be used as
a means to prepare and issue a credential or pass. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to
civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing or retention of an
employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit.
If the individual does not provide some or any part of the requested information, the employee will not be issued a credential and will not be allowed to enter a
GSA-controlled building after normal hours or when the building is under security.

GSA 850 (REV. 6/2017) BACK