General Information for Domestic Guest Researchers

OMB Control No. 0693-0067

Expiration Date: 04/30/2024

General Information for Domestic Guest Researchers
Personal Information
Guide: Attach CV/Resume
First Name	Middle Name		Last Name		Suffix (Jr. III etc.)
     	     		     		     
Gender (Select all that apply) (Optional)	Female			Male
	Transgender, non-binary, or other gender			Prefer not to answer
Phone Number
Place of Birth
Date of Birth (MM/DD/YYYY)			     
City of Birth	     		State		  
County/Province	     		Country		     
Citizenship(s) (List all if more than one)	     		SSN		     
Employed by Another U.S. Federal Agency (Y/N)			     
Mother’s Maiden Name			     
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

Guide: The NIST associate's employer or home organization can be 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, (3) a business owned by the associate, or (4) "SELF" if associate is self-employed or a retiree, and not associated with any incorporated business. Street address is mandatory for all guest researchers.

Employer/Home Organization Contact

First Name

Last Name

Phone Number

     

     

     

Organization Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Work Permit Number (Required if under 18) Only for Maryland Work Locations

     

Sponsor Information

Guide: The sponsor can be one of the following: (1) employer/home organization, (2) an organization that has signed a CRADA or IPA agreement with NIST, (3) "SELF" for associates who are retirees or self-employed and not associated with any incorporated business, or (4) other organization that sponsors the NIST Associate. Street address is mandatory for all guest researchers. City, state, and zip code are required for NIST Associates only if the country is U.S.

Sponsor Name

     

Street Address

     

Address Line 2

     

Address Line 3

     

City

     

State

  

County/Province

     

Country

     

Zip

     

Affiliations

Guide: Affiliations include any other organizations (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 Institution

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: Must provide one year 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

     

Other Names Used And Dates When 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

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 30 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.

AUTHORIZATION AND RELEASE AND CERTIFICATION
BEFORE SIGNING THIS FORM, REVIEW CAREFULLY TO ENSURE THAT YOU HAVE PROVIDED ALL REQUESTED INFORMATION FULLY AND CORRECTLY. KNOWN AND WILLING FALSE STATEMENTS ARE PUNISHABLE BY LAW.
I declare under penalty of perjury that the statements made by me on this form are true, complete and correct.	SIGNATURE	DATE

NIST Associate General Questionnaire 9