Form WHCA Form 89 WHCA Form 89 WHITE HOUSE COMMUNICATIONS AGENCY SECURITY SCREENING QUE

This questionnaire when populated with data must be emailed encrypted

WHITE HOUSE COMMUNICATIONS AGENCY
SECURITY SCREENING QUESTIONNAIRE (SSQ)
Code:_________________
Current Clearance: Secret

Date Reviewed:_______________
TS

Initials_________________

Clearance Date:______________ Projected Investigation: SSBI PR

PRIVACY ACT STATEMENT: The Authority for collecting the requested information resides in Executive Orders 10450 (Security requirements for
Government employment), 11652 (Classification and declassification of national security information and material) & 9397 (Federal Agency Use of Social
Security Numbers). The information is used in making security determinations, granting access to classified/PSD protected information and for making
personnel management decisions. Routine uses include determining the scope and coverage of a personnel security investigation, checking investigative
leads assuring completeness of the investigation, and providing evaluators and/or adjudicators with basic personal history information relevant to security/
suitability and are referenced in the SORN. Information may be disclosed to and maintained by Government agencies and administrative personnel
involved in processing security actions that evolve during the course of these determinations. When populated with data, this questionnaire becomes PII
and must be encrypted prior to transmittal. The personal data collection will be transferred into an approved system of record, under an Authority to
Operate, granted on 10 Jul 09, under federal register chronicle 78 FR 70543, 26 Nov 13, 79 FR 34299, 16 Jun 14 and maintained for up to 75 years. The
SORN allowing this collection can be found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Article-View/Article/570748/kwhc08/.

LAST NAME:

MI:_______

FIRST:

SSN:

DATE OF BIRTH: (MonthDDyYear):

PLACE OF BIRTH:

MOS/AFSC/RATE:

BRANCH OF SERVICE:

RANK/PAY GRADE:

/

DELAYED ENTRY DATE:_____________________ BASIC ACTIVE SERVICE DATE:___________________
(0RQWK'D\File Typeapplication/pdfFile TitleWHITE HOUSE MILITARY OFFICEAuthorLloyd N. ThyenFile Modified2021-09-27File Created2017-01-25