Form 10-152 National Park Service Background Investigation/Clearance

NPS Form 10-152 (Rev.09/2023)
National Park Service

OMB Control No. 1024-0282
Expiration Date XX/XX/XXXX

NATIONAL PARK SERVICE
BACKGROUND INVESTIGATION/CLEARANCE INITIATION REQUEST
Applicants for Federal Employment and Proposed
Non-Federal Personnel

INSTRUCTIONS: All applicants are required to complete Section I. Non-Federal applicants, to include proposed contractors, partners,
and cooperators, must also complete Section III below and attach a completed Form OF-306, “Declaration for Federal Employment.”
Completed forms should be submitted to the HR/Security office who provided the form to you, your agency sponsor, or your Contracting
Officer’s Representative.

SECTION I – To be Completed by Applicant/Proposed Non-Federal Personnel
Applicant for Federal Employment
Applicant for Non-Federal Personnel*

Category of
Applicant:

Contractor*
Associate*
Partner*
Intern*
Volunteer*
Other*
*Must also complete Section III below and attach completed OF-306 (Declaration for Federal Employment)

Applicant Full Name
(Must Match Documents)

Last

Social Security Number

First

Middle (

Date of Birth

Contact Telephone Number

Place of Birth

NMN)

Suffix

Country of Citizenship (

US)

Email Address
City

Home Street Address

State

Zip Code

Have you ever had a HSPD-12 background clearance initiated by another FEDERAL AGENCY?
Yes
No If “Yes”, please
provide the following:
Name of Agency
Approximate Date of Investigation
The applicant by his or her signature certifies that all the information given is complete
and correct, and that no false or misleading information or false statements have been given.
Signature of Applicant
Date

SECTION II – To be Completed by Agency Sponsor/Requestor Only
Name of Agency Sponsor/Requestor

Organization (Directorate/Division/Office)

Office Phone Number

Organization (Directorate/Division /Office/Region/Park)

Organizational Code

Account Number (for Background Investigation Charges)

Type of Background Investigation Requested
Low Tier (LT)

Card Ship Facility and Address
Federal Emergency Response Official (FERO)

City
Yes

No

Mid Tier (MT)
State

Network Access

Yes

High Tier (HT)
Zip Code

No

UPN:

SECTION III – Additional Information Required for Proposed Non-Federal Personnel

Contract/Agreement Period of Performance (POP)

Company Employing Proposed Non-Federal Personnel

Start
Contract/Agreement Number
Signature of Agency Sponsor/Requestor

End

Completed Form OF-306 attached
Date

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Management and Accountability, (Item 10D)
(N1-79-08-9))

NPS Form 10-152 (Rev.09/2023)
National Park Service

OMB Control No. 1024-0282
Expiration Date XX/XX/XXXX

NATIONAL PARK SERVICE
BACKGROUND INVESTIGATION/CLEARANCE INITIATION REQUEST
Applicants for Federal Employment and Proposed
Non-Federal Personnel

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Management and Accountability, (Item 10D)
(N1-79-08-9))

NPS Form 10-152 (Rev. 09/2023)
National Park Service

OMB Control No. 1024-0282
Expiration Date XX/XX/XXXX

NOTICES
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing
this form.
Authority: The authority to collect information on the attached form is derived from one or more of the following:
Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301; sections 8(b), 8(c), and
9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22, United States Code, sections 1434 and 2585.
Purposes and Uses: The collection, maintenance, and disclosure of background investigative information are governed by the Privacy
Act. This information is being collected for the purpose of conducting a suitability background investigation, and the information will be
protected from unauthorized disclosure. In line with new regulations mandated by the U.S. Office of Personnel Management Investigative
Services and the Department of the Interior (DOI), the National Park Service (NPS) Personnel Security Branch is utilizing the Electronic
Questionnaires for Investigations Processing (E-QIP) System. As a result, electronic submission of the standard form 85, for suitability
background investigations (NACI) or the Standard Form 85P, for Public Trust, is now required. The DOI and NPS requires all Federal
employees and non-Federal personnel requiring access to NPS property and/or receive a DOIAccess badge to be processed for a
suitability background investigation, in accordance with Executive Order 10450 and the Homeland Security Presidential Directive (HSPD12). The Department of the Interior and the National Park Service requesting the background investigation have published notices in the
Federal Register describing the systems of records in which your records will be maintained. Information from the contractor may be
transferred to appropriate Federal, State, local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.
Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001,
provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or
both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Special Use
Permit
Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security
Number (SSN) is needed to identify records unique to you. Applicants are required to provide their social security or taxpayer identification
number for activities subject to collection of fees and charges by the National Park Service (31 U.S.C. 7701). Although disclosure of your
SSN is not mandatory, failure to disclose your SSN may prevent or delay the initiation of your background clearance and subsequently,
your approval to be granted physical and/or electronic access to NPS offices and computer systems. The authority for soliciting and
verifying your SSN is Executive Order 9397. The information gathered through the use of the SSN will be used only as necessary for
processing this application and will be carried out in accordance with established regulations and published notices of system of records
(Interior/DOI-45, “HSPD-12: Identity Management System and Personnel Security Files,” 86 FR 50156; September 7, 2021).
Paperwork Reduction Act Statement
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the National Park Service with the
information needed to initiate a background clearance. All applicable parts of the form must be completed in order for your request to be
considered. You are not required to respond to this or any other Federal agency-sponsored information collection unless it displays a
currently valid OMB control number.
Estimated Burden Statement
Public reporting burden for this form is estimated to average 7 minutes per response including the time it takes to read, gather and
maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form,
to the Information Collection Clearance Officer, National Park Service, 13461 Sunrise Valley Drive, (MS-244) Reston, VA 20191.
Please do not send your completed form to this address.