General Information for NIST Foreign National Associates (FNAs)

OMB Control No. 0693-0067

Expiration Date: 04/30/2024

General Information for NIST Foreign National Associates (FNAs)
Personal Information
Guide: Attach CV/Resume and Passport ID Page
First Name	Middle Name			Last Name			Suffix (Jr. III etc.)
          	          			          			     
Gender (Select all that apply) (optional)	Female				Male
	Transgender, non-binary, or another gender				Prefer not to answer
Phone Number
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)				     		US-CIS #		     
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)				     
Passport Expiration Date				     
Contact Information for NIST Associate (prior to arrival)
Guide: An e-mail address is required for security processing in e-App (Electronic Application 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 (U.S. and Foreign Based) with whom the associate has a formal relationship or obligations within the last 5 years. Street address, City, State, Country and zip code (if applicable) is mandatory for all NIST associates.
Affiliate Name	     
Street Address	     
Address Line 2	     
Address Line 3	     
City	     	State		  
County/Province	     	Country	     	Zip	     
Dates Attended	From		To
	     		     

Affiliate Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Dates Attended

From

To

     

     

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, Country and zip code (if applicable) 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

Tip: The correct format for entering dates attended is "MM/01/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 Present

     

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/Day/Year to Month/Day/Year

     

Month/Day/Year to Month/Day/Year

     

Month/Day/Year to Month/Day/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 International and Academic Affairs Office (IAAO) 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

Privacy Act Statement

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why the U.S. Department of Commerce (the Department), National Institute of Standards and Technology (NIST) is requesting the information on this form.

AUTHORITY:

The collection of this information is authorized under the NIST Organic Act, Title15 U.S.C. § 272 (b)(10) and (b)(11) and the Paperwork Reduction Act (PRA), 44U.S.C. § 3501 et seq., Information collected for facility access determinations and is authorized by Executive Order 10450 and/or Section 231 of the Crime Control Act of 1990, and Executive Order 9397.

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.   

ROUTINE USES:

The information solicited on this form may be made available as a “routine use” pursuant to 5 U.S.C. § 552a(a)(7) and (b)(3).  The information may be made available to other federal agencies to assist the Department in connection with NIST’s management of the purposes stated above; or for other authorized routine uses.  A complete list of the routine uses can be found in the system of records notice associated with this form:

NIST-1: NIST Associates https://www.osec.doc.gov/opog/privacyact/privacyact_sorns.html

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:

Providing this information is voluntary.  However, failure to provide the requested information may result in an inability for NIST to process, review, and/or act on such requests.  In limited circumstances, NIST may authorize the submission of the requested information via paper forms pursuant to the requirements in 15 CFR 748.1(d).

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 50 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.

NIST Associate General Questionnaire 10