General Information for NIST Foreign National Associates (FNAs)

OMB Control No. 0693-0067

Expiration Date: 09/30/2022

General Information for NIST Foreign National Associates (FNAs)
Personal Information
First Name	Middle Name			Last Name		Suffix (Jr. III etc.)
          	          			          		     
Gender	     
Place of Birth
Date of Birth (MM/DD/YYYY)				     
City		     		State		  
County/Province		     		Country		     
Citizenship(s) (list all if more than one)		     
Language(s) Spoken		     
Social Security Number				     
Are you a Permanent U.S. Resident? (Y/N)				     
Employed by another U.S. federal government agency (Y/N)				     
Mother’s Maiden Name				     
Passport Issuing Country (for U.S. entry)				     
Passport Number (for U.S. entry)				     
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:      
Emergency Personal Contact
Guide: A phone number must be provided for the contact.
First Name				Last Name
     				     
Phone Number			     
Employer/Home Organization Contact
First Name			Last Name		Phone Number
     			     		     

Employer/Home Organization

Guide: The NIST associate's employer or home organization is 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, or (3) a business owned by the associate. Street address, City, State and zip code is mandatory for all NIST associates.

Organization Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Sponsor Information

Guide: The sponsor is one of the following: (1) employer/home organization, (2) an organization that has signed a CRADA or IPA agreement with NIST, or (3) other organization that sponsors the NIST Associate. Street address, City, State and zip code is mandatory for all NIST associates.

Sponsor Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Affiliations
Guide: Affiliations include any other organization with whom the associate has a formal relationship or obligations. Street address, City, State and zip code is mandatory for all NIST associates.
Affiliate Name	     
Street Address	     
Address Line 2	     
Address Line 3	     
City	     	State		  
County/Province	     	Country	     	Zip	     

Affiliate Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Other Funding Sources

Guide: Funding Sources can be any of the following (1) National Scholarships; (2) Foundation scholarships; (3) International scholarships; or (4) any other funding to support the NIST Associate Street address, City, State and zip code is mandatory for all NIST associates.

Funding Organization

Street Address

Address Line 2

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Funding Organization

Street Address

Address Line 2

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Education Information

Guide: Please attach your CV/resume.

Tip: The correct format for entering dates attended is "MM/DD/YYYY."

Educational Institutions (please include all attended)

Highest Degree(s) Awarded

     

School Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Subjects Studied

     

Dates Attended

From

To

     

     

Highest Degree(s) Awarded

     

School Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Subjects Studied

     

Dates Attended

From

To

     

     

Highest Degree(s) Awarded

     

School Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Subjects Studied

     

Dates Attended

From

To

     

     

Home Address

Guide: If non-PR, must provide the last 3 years of residence history.

Tip: If additional space is needed, please attach a continuation sheet to this form.

Month/Year to Month/Year

     

Street

     

City

     

County/Province

     

State

     

Country

     

Zip/Postal Code

     

Month/Year to Month/Year

     

Street

     

City

     

County/Province

     

State

     

Country

     

Zip/Postal Code

     

Month/Year to Month/Year

     

Street

     

City

     

County/Province

     

State

     

Country

     

Zip/Postal Code

     

Last 3 U.S. Entries in the Past 5 Years

Month/Year to Month/Year

     

Month/Year to Month/Year

     

Month/Year to Month/Year

     

Other Names Used and Dates 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

     

     

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

This Section is Collected Upon Arrival to NIST

Visa for U.S. Entry

• I-94

• Visa stamp

Health Insurance

Guide: Required for Associates with NIST sponsored J1 Visa and their dependents.

• Health Insurance Company Name

• Policy Start Date

• Policy End Date

CERTIFICATE OF INSURANCE

This form is required only for Guest Researchers on a J-1 visa sponsored by NIST.

GUEST RESEARCHER’S NAME:

Home Organization:

J-2 dependents who accompanied you to the United States (if applicable):

Name: Relationship

Name: Relationship

Name: Relationship

Name: Relationship

Name: Relationship

Name: Relationship

I certify that I, and my dependents (listed above), have insurance which meets or exceeds the following coverage:

1. Medical benefits of at least $100,000 per accident or illness;

2. Repatriation of remains in the amount of $25,000

3. Expenses associated with the medical evacuation of the exchange visitor to his or her home country in the amount of $50,000; and

4. A deductible not to exceed $500 per accident or illness.

Coverage period from to _

For dependents (if applicable)

Coverage period from to _

Name of Insurance Company __________________________

I have enrolled in the above insurance program. I will continue to maintain this coverage and will notify the Office of International and Academic Affairs (OIAA) of any changes and provide appropriate documentation of any changes. I will also provide documentation of continuation of the required coverage if J-1 status Is extended.

Signature & Date of Guest Researcher

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0693-0067. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are required to obtain benefits. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the National Institute of Standards and Technology at: 100 Bureau Drive, MS 2200, Gaithersburg, MD 20899 Attn: Technology Partnerships Office.

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.

NIST Associate General Questionnaire 10