ADM-045 Site Inspection Checklist

ADM-045
USDA NASS
OMB No. XXXX-XXXX

NATIONAL
AGRICULTURAL
STATISTICS
SERVICE

Approval Expires:

SITE INSPECTION CHECKLIST

U.S. Department of Agriculture
1400 Independence Avenue, SW
Washington, DC 20250

Request No ________________

NASS Representative: ____________________________________
Researcher Name: ____________________________________
Researcher Org: ____________________________________
Address: ____________________________________

____________________________________
Phone Number: ____________________________________
A NASS authorized representative must perform a virtual site inspection of the remote data access point workplace to complete
form. Forward completed form to the REE-NASS-PhysicalSecurity@usda.gov for review and approval.

WORKPLACE DESCRIPTION/ PHYSICAL SECURITY/CONFIDENTIALITY

1
2
3
4
5
6
7
8

Home or Office?
a. Floor and room number
Isolated from public areas within the building?
Accessible by authorized individuals only?
Located inside a lockable room?
Monitor is not visible from windows or doors?
Researcher has signed NASS ADM-043.
Researcher is aware that screen sharing, screen
capture, printing, photography, or any other form of
data replication is prohibited.

Home

Office

YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO

YES

NO

MACHINE INFORMATION

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10
11
12

Manufacturer
Model Number
Serial Number
IP Address (IPv4)

_____________________________________
NASS Representative Signature and Date

FOR NASS SECURITY STAFF USE ONLY

Approved:

Yes

No

NASS Security Staff Signature and Date:

Sensitive But Unclassified (SBU) Information Disseminate only on a Need to Know Basis
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB number is xxxx-xxxx. The time required to complete this information collection is estimated to
average 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 collection of information.