Form 2962 Personnel Security System Access Request

CUI (when filled in)
Name (Last, First, Middle Initial):

PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR)
DEFENSE COUNTERINTELLIGENCE AND SECURITY AGENCY (DCSA)

OMB No. 0704-0542
OMB approval expires
XXXXXXXX

The public reporting burden for this collection of information, 0704-0542, is estimated to average 10 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for
failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. Return completed form to the
appropriate Account Manager or DCSA Contact Center, as indicated in the instructions.

PRIVACY ACT STATEMENT
AUTHORITY: E.O. 12829, National Industrial Security Program; E.O. 10450, Security Requirements for Government Employment; E.O. 10865, Safeguarding Classified Information Within Industry;
(DoDI) 1400.25, Volume 731, DoD Civilian Personnel Management System: Suitability and Fitness Adjudication for Civilian Employees; DoDM 5200.02, Procedures for the DoD Personnel Security
Program; DoDI 5200.02, DoD Personnel Security Program (PSP); DoDD 5220.6, Defense Industrial Personnel Security Clearance Review Program; DoDI 5220.22, National Industrial Security
Program (NISP); DoDI 5200.46, DoD Investigative and Adjudicative Guidance for Issuing the Common Access Card (CAC); Homeland Security Presidential Directive (HSPD) 12, Policy for Common
Identification Standard for Federal Employees and Contractors; and E.O. 9397 (SSN), as amended.
PURPOSE(S): To request the establishment of user roles and access and validate the trustworthiness of individuals seeking access to Defense Central Index of Investigations (DCII), DoD Secure
Web Fingerprint Transmission (SWFT), DoD Defense Information system for Security (DISS) or National Background Investigation Services (NBIS).
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. See the appropriate System of Records Notice for the applicable
routine uses: A complete list of the routine uses can be found in the system of records notice for the Department of Defense Personnel Vetting Records System, “DUSDI 02-DoD” at: https://
www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records; DUSDI 02-DoD, Personnel Vetting Records System at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/OSDJS-Article-List/
DISCLOSURE: Voluntary. However failure to provide the requested information may impede, delay, or prevent further processing of your request. The Social Security Number is used to verify the
trustworthiness status.

PART 1 - PERSONAL INFORMATION
1. NAME (Last, First, Middle Initial)

2. ORGANIZATION

3. OFFICE SYMBOL / DEPARTMENT

4. PHONE (DSN or Commercial)

5. OFFICIAL E-MAIL ADDRESS

6. JOB TITLE AND GRADE/RANK

7. OFFICIAL MAILING ADDRESS

8. CITIZENSHIP

11. SOCIAL SECURITY NUMBER

10. PLACE OF BIRTH (City & State/Country)

13. DESIGNATION OF APPLICANT

9. DATE OF BIRTH (YYYYMMDD)

MILITARY

DoD CIVILIAN

12. CAGE CODE (CTR Only)

INDUSTRY

NON-DoD

PART 2 - APPLICATIONS
14. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (GOVERNMENT ONLY)
TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

a. DCII AGENCY CODE

OR DCII AGENCY ACRONYM

b. USER PERMISSIONS:
ADD

QUERY (Search)

UPDATE

DELETE

FILE DEMAND
(Provide Accreditation Code):

AGENCY ADMINISTRATOR

EXECUTIVE ADMINISTRATOR

FILE DEMAND PRINT

IA (ROOT ADMINISTRATOR)

SITE ADMINISTRATOR

ORGANIZATION/COMPANY
ADMINISTRATOR

15. SECURE WEB FINGERPRINT TRANSMISSION (SWFT)
TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

a. PERMISSIONS - FINGERPRINT SUBMISSION:
USER

MULTI-SITE UPLOADER

b. PERMISSIONS - FINGERPRINT ENROLLMENT:
ENROLLER

TRANSACTION VIEWER

ENROLLER SITE ADMINISTRATOR
OTHER

c. ADDITIONAL CAGE/ORGANIZATION CODE(S):

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ENROLLER GROUP ADMINISTRATOR

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Controlled by: OUSD (I&S)
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Controlled by: DCSA
CUI Category: Provisional – Sensitive Personally Identifiable Information
Distribution/Dissemination Control: Personnel Security System Users
POC: sandra.m.langley.civ@mail.mil

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Name (Last, First, Middle Initial):
16. DEFENSE INFORMATION SYSTEM FOR SECURITY - JOINT VERIFICATION SYSTEM (DISS-JVS)
TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

a. SMO NAME:

ORGANIZATION/AGENCY CODE:

b. ROLE REQUESTED AND OPTIONAL PERMISSIONS (Mark All That Apply):
SECURITY OFFICER

SECURITY OFFICER ADMIN
UPDATE SUBJECT
INFORMATION
GRANT NON-SCI
ACCESS
REMOVE NON-SCI
ACCESS
ESTABLISH SUBJECT
RELATIONSHIP
MANAGE FOREIGN
RELATIONSHIPS
REMOVE SUBJECT
RELATIONSHIP

MANAGE POLYGRAPH
VIEW SCI ACCESS
MANAGE SCI ACCESS
REVIEW INVESTIGATION
REQUEST
COMPONENT ADJUDICATOR

HUMAN RESOURCE MANAGER

CREATE VISIT
PHYSICAL ACCESS CONTROL

VIEW VISIT

SECURITY MANAGER
SUSPEND ACCESS

MANAGE POLYGRAPH

MANAGE TASKS

VIEW SCI ACCESS

MANAGE POLYGRAPH

MANAGE SCI ACCESS

VIEW SCI ACCESS

REVIEW INVESTIGATION
REQUEST

MANAGE SCI ACCESS
VIEW SMO
NOTIFICATIONS
MANAGE FOREIGN
TRAVEL

HIERARCHY MANAGER
VIEW SCI ACCESS
MANAGE SCI DISS USER

MODIFY VISIT

VIEW SCI ACCESS

ACCOUNT MANAGER
SECURITY OFFICER VISIT ADMIN

PRIVACY OFFICER

VIEW SCI ACCESS

VIEW SUBJECT LIST

MANAGE SCI DISS USER

VIEW SCI ACCESS
HELP DESK

APPLICATION ADMIN

ESTABLISH SUBJECT RELATIONSHIP
REMOVE SUBJECT RELATIONSHIP
OTHER ROLES AND PERMISSIONS
EXPLAIN
OTHER

17. DEFENSE INFORMATION SYSTEM FOR SECURITY - CASE ADJUDICATION TRACKING SYSTEM (DISS - CATS)
TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

a. APPLICATION LOCATION: ORGANIZATION

DIVISION

BRANCH

TEAM

b. ROLE REQUESTED:
EXECUTIVE CHIEF

ADJUDICATOR

PE SCREENER

PROCESS TEAM

DIVISION CHIEF

TRAINEE

GENERAL COUNSEL

INDUSTRY PROCESS TEAM

BRANCH CHIEF

IT SCREENER 1

OPM LIAISON

QUALITY CONTROL

TEAM CHIEF

IT SCREENER 2

METRICS

PRIVACY OFFICER

CV SCREENER

IT SCREENER 3

ADMINISTRATOR

c. LIST ANY ELEVATED PERMISSIONS:

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Name (Last, First, Middle Initial):
18. DEFENSE INFORMATION SYSTEM FOR SECURITY - APPEALS
TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

a. APPLICATION LOCATION: ORGANIZATION

DIVISION

BRANCH

TEAM

b. ROLE REQUESTED AND OPTIONAL PERMISSIONS (Mark All That Apply):
DOHA ADMIN

PSAB ADMIN

MANAGE APPEALS USER

MANAGE APPEALS USER

PSAB BOARD MEMBER

PRIVACY OFFICER

HELP DESK

APPLICATION ADMIN

19. NATIONAL BACKGROUND INVESTIGATION SERVICES (NBIS)
TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

a. ROLE REQUESTED:
SYSTEM MANAGER

AUTHORIZER (GOVERNMENT
ONLY)

WORKFLOW MANAGER

BUSINESS PROCESS MANAGER

INTERNAL ORG MANAGER

NBIS FINANCIAL MANAGER

INITIATOR

ORG MANAGER

WORKLOAD MANAGER

FINANCIAL MANAGER

POINT OF CONTACT

REVIEWER

USER MANAGER

INTERNAL USER MANAGER

NOTIFICATION MANAGER

ORDER FORM TEMPLATE
MANAGER

OTHER
b. LIST ANY ELEVATED PERMISSIONS:

PART 3 - TRAINING (I have completed and attached training certificates for):
20.

CYBER AWARENESS TRAINING

DATE (YYYYMMDD)

21.

PERSONALLY IDENTIFIABLE INFORMATION TRAINING

DATE (YYYYMMDD)

PART 4 - APPLICANT'S CERTIFICATION
I hereby certify that I understand that by signing this Personnel Security System Access Request, I am solely responsible for the use and protection of the
account that I will be provided. I also understand that I am not authorized to share my account or logon credentials with any other individuals. I will utilize all tools
and applications in accordance with the account management policy and security policy, as well as all applicable U.S. laws and DoD regulations. I understand
that if I violate any account management policy, security policy, U.S. laws or DoD regulations, my account will immediately be terminated, and may be subject to
criminal charges and penalties.
22. APPLICANT'S SIGNATURE

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23. DATE (YYYYMMDD)

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PART 5 - NOMINATING OFFICIAL'S CERTIFICATION
24. I certify that the above named individual meets the requirements for access, has the appropriate need-to-know, and if applicable, meets the
requirements for account management privileges. I am also aware that I am responsible for ensuring this individual will follow all account policies,
security policies, and all applicable DoD regulations and U.S. laws. Furthermore, I certify that the named applicant requires account access as
indicated above in order to perform assigned duties.
25. NOMINATING OFFICIAL'S PRINTED NAME (Last, First, Middle Initial)

27. NOMINATING OFFICIAL'S TELEPHONE NUMBER

26. NOMINATING OFFICIAL'S TITLE

28. NOMINATING OFFICIAL'S SIGNATURE

29. NOMINATING OFFICIAL’S SIGNATURE DATE

PART 6 - VALIDATING OFFICIAL'S VERIFICATION
I have verified that minimum investigative requirements for the above applicant have been met and the applicant has the necessary need-to-know to
access the personnel security systems requested.

30. ELIGIBILITY/ACCESS LEVEL:

31. TYPE OF INVESTIGATION:

32. ELIGIBILITY GRANTED DATE:

33. DATE INVESTIGATION COMPLETED:

34. ELIGIBILITY ISSUED BY:

35. INVESTIGATION CONDUCTED BY:

36. VALIDATING OFFICIAL’S PRINTED NAME (Last, First, Middle Initial):

37. VALIDATING OFFICIAL'S SIGNATURE (Last, First, Middle Initial):

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38. VALIDATING OFFICIAL’S SIGNATURE DATE

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Name (Last, First, Middle Initial):

PART 7 - PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR) INSTRUCTIONS
Please see the respective Account Management Policy available from the DCSA website for supplemental guidance on completing and submitting this form.

Type of Request. Select "initial" for a new account, "modification" for a
change in privileges to an existing account, "deactivate" to remove all
access and disable an existing account. Enter User ID if selecting
"modification" or "deactivate."
Date. Date request is submitted by applicant.
Part 1 - Personal Information.
1. Name. Last Name, First Name, Middle Initial of applicant. If no
middle initial, enter "NMN."
2. Organization. Employing organization or company name of
applicant.
3. Office Symbol/Department. Employing department or office.
4. Phone. Telephone number of Applicant. Enter DSN or Commercial
as appropriate.
5. Official E-mail Address. Official e-mail address of Applicant to be
used for account communication.
6. Job Title and Grade/Rank. Job title and pay grade or military rank of
Applicant.
7. Official Mailing Address. Official mailing address of Applicant.
8. Citizenship. Country of citizenship. If dual, enter both countries.
9. Date of Birth. Applicant's date of birth.
10. Place of Birth. City and state, if born in the U.S. Otherwise, enter
city and country.
11. Social Security Number. Social Security Number (SSN) is
required.
12. CAGE Code. Contractor only: CAGE code of Applicant.
13. Designation of Applicant. Mark in the appropriate box for DoD
(e.g., military branches, DoD agencies, DoD contractor companies),
non-DoD NISP partner and non-DoD affiliated.
Part 2 - Applications.
14. DCII.
a. DCII Agency Code/DCII Agency Acronym. Complete if requesting
a DCII account. Provide the DCII Agency Code/DCII Agency Acronym if
previously assigned by DCII Administrator and known. Otherwise,
contact DMDC Contact Center for assistance.
b. User Permissions. Requested User permissions are restricted to
those granted to the Agency. Elevated permissions for the Agency must
be requested from DCII Program Manager.
15. SWFT.
a. Permissions - Fingerprint Submission. Applies to SWFT users.
Indicate the requested user permission(s) by marking the appropriate
box, or list in Item.
b. Permissions - Fingerprint Enrollment. Indicate the requested user
permission(s) by marking the appropriate box. Only complete this
section if you have or request a SWFT account (Government Only) and
are cleared to use the web-based fingerprint enrollment system.
c. Additional CAGE Code(s). List only if different from box 12 of this
form. Cannot add CAGE or Organization code(s) to account with MultiSite Uploader permission. The Nominating Official must have the
authority to permit the use of the CAGE Code(s) by Applicant.
16. DISS (JVS).
a. SMO Name or Organization/Agency Code. Security Management
Office name or Organization/Agency code.
b. Role Requested and Optional Permissions. Indicate the requested
user role(s) by marking the appropriate box, along with any optional
permissions requested.
17. DISS (CATS).
a. Application Location. Organization Name, Division Name, Branch
Name, Team Name.
b. Role Requested. Indicate the requested user role(s) by marking the
appropriate box.

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c. List any Elevated Permission(s). This information is requested by
the user.
18. DISS - APPEALS.
a. Application Location. Organization Name, Division Name, Branch
Name, Team Name.
b. Role Requested. Indicate requested user role(s) by marking the
appropriate box, along with any optional permission requested.
19. NBIS.
a.Role Requested. User Role being requested for system access.
b.Elevated Permissions. Optional permissions for requested roles.
Part 3 - Training.
20 - 21. Training Requirements. Mark in the box to certify training
units completed and enter completion date for new accounts.
Certificates must be submitted with PSSAR within one year of training
completion date.
Part 4 - Applicant's Certification.
22. Applicant's Signature. Signature of Applicant acknowledging DoD
and system policies.
23. Date. Date application signed by Applicant.
Part 5 - Nominating Official's Certification.
24. Nominating Official’s Certification Statement.
25. Nominating Official’s Printed Name. Last Name, First Name, and
Middle Initial. If no middle initial, enter "NMN."
26. Nominating Official's Title. Title of Nominating Official.
27. Nominating Official's Telephone Number. DSN or Commercial
telephone number.
28. Nominating Official's Signature. Nominating Official's Signature.
The Nominating Official is the individual who is authorizing that the
Applicant should have the access requested. The Nominating Official
must be a Key Management Personnel (KMP) listed in NISS, Facility
Security Officer, or Security Officer/Manager. The Nominating Official
CANNOT be the same as the Applicant unless it is a single person
facility.
29. Nominating Official's Signature Date.
Part 6 - Validating Official's Verification.
Do not complete if self-nominating/validating.
30. Eligibility/Access Level. Eligibility/Access level of Applicant. See
applicable System Account Management Policies/Access Request
Procedures available from the respective DCSA website for minimum
eligibility/access requirements.
31. Type of Investigation. Type of investigation completed for
Applicant.
32. Eligibility Granted Date. Date clearance granted, indicating if
interim. If not final, state date of interim.
33. Date Investigation Completed. Date investigation completed.
34. Eligibility Issued By. Organization that issued clearance.
35. Investigation Conducted By. Investigating agency.
36. Validating Official's Printed Name. Last Name, First Name, and
Middle Initial. If no middle initial, enter "NMN."
37. Validating Official's Signature. The Validating Official signature
serves to affirm the information provided on the following lines (verify
before signing): Eligibility/Access Level; Eligibility Issued By; Type of
Investigation and Investigation Conducted By. For non-DoD
government agency requests, the Chief of Security or designee must
complete this section.
38. Validating Official's Signature Date. Date Investigation
Completed.

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