Appendix B FNS 775 EmpowHR Person Model

EmpowHR/Person Model
NON-EMPLOYEE DATA SHEET
Privacy Act Statement. The following information is provided in accordance with 5 U.S.C. § 552a(e)(3) and
M-03-22.
Authority: This information is being collected under the authority 5 U.S.C. 7312 and 7532 and Executive Order 10450.
Purpose: This information is collected to conduct background investigations which is a pre-requisite for all non-FNS
employees (contractor, intern, volunteers, etc.) to be granted a security clearance for employment at all FNS locations.
Routine Uses: The information you provide on this form may be shared with other federal, state, local, and foreign
government agencies and authorized organizations following approved routine uses described in the associated
published system of records notice [USDA/OP-2 - Security Records for USDA Employees, which can be found at
https://www.usda.gov/home/privacy-policy/system-records-notices].
Disclosure: Disclosing the information is voluntary. However, if you do not provide the information requested, we
cannot process the request for affiliation with our agency.

OMB Control Number: 0584-XXXX
Expiration Date: xx/xx/xxxx

The data collected on this sheet is used to input the USDA, Food and Nutrition Service's non-employee
(contractor, intern, volunteer, etc.) information into EmpowHR /Person Model. The data collected is for the
specific purpose of sponsorship for the agency's PIV credential and background investigation required for
access to agency facilities, systems, and information. When completed, this form contains Personally
Identifiable Information. Safeguard according to agency policy.
Public reporting burden for this collection of information 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. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture,
Food and Nutrition Services, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA
22314 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.

Non-Employee Information
Full Legal NAME (Last, First, Middle, Suffix)

MALE
FEMALE

LINCPASS REQUIRED
YES

APARTMENT/UNIT NUMBER

HOME ADDRESS

CITY

STATE

ZIP CODE

BUSINESS ADDRESS

SUITE NUMBER

CITY

STATE

PRIMARY PHONE (Area code + number) ALTERNATE PHONE (Area code + number)

BIRTH DATE (MM/DD/YYYY)

AFFILIATION TYPE

NO

ZIP CODE

BUSINESS EMAIL ADDRESS

SOCIAL SECURITY NUMBER

COUNTRY OF CITIZENSHIP

PLACE OF BIRTH (City, state, country if not USA)

Contract /Agreement Assignment and COR /Sponsor Information
COMPANY NAME

CONTRACT/GRANT OR AGREEMENT NUMBER

COR /SPONSOR NAME

COR/SPONSOR WORK PHONE NUMBER

PLANNED EXIT DATE

COR/SPONSOR CELL PHONE (Area code + number)

Position Risk Designation (See notes below)
Sponsor Signature

Position Risk Designation Notes

As required by section 1400.201(b) of title 5, Code of Federal Regulations (CFR), this system is for uniform and consistent position designation of any positions, including contractor
employee positions, when the investigation will be conducted under the Federal Investigative Standards prescribed by the Office of Personnel Management and the Office of the
Director of National Intelligence in December 2012. Pursuant to an assignment of functions under section 2.2(e) of E.O. 13467, the December 2012 Federal Investigative Standards
apply to investigations for contractor employee fitness.
The Contracting Officer’s Representative (COR) will use the OPM Automated Position Designation Tool, to determine the appropriate position designation requirement for all
contractor employee positions. If you have any questions in using the OPM Automated Position Designation Tool or in designating the position, consult with the FNS HRD Personnel
Security Specialist. The tool can be found here: https://www.opm.gov/suitability/suitability-executive-agent/position-designation-tool/
The position designation system consists of a four-step process that will guide the designator through an examination of the position’s duties and responsibilities. The completion of
this process will result in a final designation for the position which, in turn, will determine the investigative requirements for the contractor employee position.

High Risk / Tier 4 and National Security Designated Position / Tier 3 and Tier 5
Contractors/Affiliates: It is anticipated that no contractors will require a high risk or national security investigation. If there may be a need, please contact the FNS HRD Personnel
Security Specialist for guidance.
Moderate Risk / Tier 2
Contractors/Affiliates: The Tier 2 is the level of investigation needed for contract personnel performing for a period of 180 days or greater with responsibilities such as database
administration, software development, technical maintenance, LAN administration, or duties that involve substantial access to sensitive information. The Tier 2 will require reinvestigation every five years.
Low Risk / Tier 1
Contractors/Affiliates: Contractors performing for a period of 180 days or greater not categorized in any of the previous categories are considered to require Tier 1 background
investigations. The Tier 1 investigation is the minimum required investigation for the issuance of the USDA LincPass. The Tier 1 remains in force indefinitely, but requires an updated
fingerprint check (SAC) every five years.
FINGERPRINT CHECK (SAC)
Contractors/Affiliates: Contractors performing for a period of less than 180 days require a finger print check. The SAC is the minimum required investigation for an interim fitness
determination and for issuance of the LincPass while the appropriate Tiered investigation is in process.

FORM FNS-775 (06/22) Previous Editions Obsolete
Electronic Form Version Designed in AEM 6.4Version

SBU

Non-Employee Data Sheet