Form TSA Form 2817B TSA Form 2817B SSI ACCESS THREAT ASSESSMENT QUESTIONNAIRE - STANDARD

OMB No. 1652-0042; Exp. xx/xx/202x

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

SSI ACCESS THREAT ASSESSMENT QUESTIONNAIRE - STANDARD

INSTRUCTIONS: Applicant: (1) Complete Section I. (2) Review the application for accuracy and complete Section II. (3) Submit the signed form and all supporting documentation to the program office. (Note: If Known Traveler Number, prior Federal background investigation, or active security clearance is available, do not complete steps 4 and 5 of these instructions unless instructed by TSA.) (4) Complete SSI Access Pre-Enrollment. (5) Schedule a date/time for your in-person SSI Access enrollment at your preferred enrollment center location. Program Office: Review Section I for completion of required information. (2) Verify the request is signed by the Applicant (Section II). (3) Submit the form to TVS after confirming appointment completed, if required. Use: For use with members of the public (i.e., non-federal) seeking access to SSI through non-contractual agreement (e.g., conditional disclosures, 15e).
Section I. Contact and Personal Information (All Types)
Full Legal Name (last, first, MI)
Aliases and/or Prior Names, if any			Social Security Number (optional)
Name of Employer (optional)		Work Phone Number (optional)			Date of Birth (mm/dd/yyyy)
Email Address (optional)		Place of Birth (City, State, Country)
Country of Citizenship				Gender
Alien Registration Number, if applicable	Non-Immigrant Visa Number, if applicable			Known Traveler Number (KTN)
Passport Country and Number (optional)
Prior Federal Background Investigation or Active Security Clearance for access to classified national security information under E.O. 12958?				If 'Yes', enter date (mm/dd/yyyy)
Reason for Requesting Access to SSI
Section II. Acknowledgments
1 - Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Applicant Signature: Date
2 - Should I seek judicial review of TSA’s final decision on my threat assessment, I authorize TSA to release the foregoing and any other information related to my threat assessment to the court(s) presiding over that review.
Applicant Signature: Date

PRIVACY ACT STATEMENT: AUTHORITY: 49 USC § 114; HR 5441 Section 525(d); 49 CFR Part 1520. PRINCIPAL PURPOSE(S):

TSA will use this information to conduct a threat assessment on individuals who seek access to Sensitive Security Information (SSI). ROUTINE USE(S): This information may be shared with law enforcement, intelligence, or other government agencies as necessary to identify and respond to potential or actual threats to transportation and under the Privacy Act routine uses identified in the TSA system of records, DHS/TSA-002 Transportation Security Threat Assessment System. DISCLOSURE: Furnishing this information is voluntary; however, failure to provide the requested information may delay or prevent TSA from completing your security threat assessment, without which you will not be granted access to SSI.

PAPERWORK REDUCTION ACT STATEMENT: TSA is collecting this information to conduct a threat assessment to determine your eligibility to gain access to Sensitive Security Information (SSI). This is a voluntary collection of information, but failure to provide the information may result in an inability to approve your eligibility to gain access to SSI. TSA estimates that the total average burden per response associated with this collection is approximately 15 minutes. If you have any comments regarding this form, you may write to: ATTN: TSA PRA Officer, TSA-11, 601 S. 12th Street, Arlington, VA, 20598-6011. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB number for this for is

1652-0042, which expires xx/xx/202x.

TSA Form 2817B (1/21) rev. [File: 2800.9.2-a]

Previous editions of this form are obsolete

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