Justification for requested security clearance




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JUSTIFICATION FOR REQUESTED SECURITY CLEARANCE

Instructions: This form is to be prepared and submitted for each security clearance requested. The justification statement must specifically explain the need for access to classified national security information and the highest level of access required. See the following instructions for additional help.

EMPLOYEE NAME:

     


POSITION TITLE:

     


GRADE LEVEL:

     


AGENCY:

     


OFFICE:

     


SSN (Last 4):

     



STATUS:

Employee Contractor Other



POSITION SENSITIVITY LEVEL:

 Special Sensitive (4)

 Critical Sensitive (3)

 Non-Critical Sensitive (2)




CLEARANCE LEVEL REQUESTED:

 TS/SCI (4)

 Top Secret (3)

 Secret (2)

 Confidential (1)


CLEARANCE JUSTIFICATION:

(Please read the attached instructions for acceptable justifications and further instruction. If an Interim clearance is needed due to exceptional circumstances, please specifically state reasons why in your justification. See page 2)
     

DATE OF REQUEST:

     

REQUESTING OFFICIAL: (printed)

     

REQUESTING OFFICIAL: (signature)

I have read the justification statement above relating to the need for a security clearance. If granted, I will be required to sign a Nondisclosure Agreement at the time of my initial security briefing. I am also aware that if this clearance is granted at the Top Secret level that I will be subject to random drug testing.
EMPLOYEE’S SIGNATURE:

DATE:

Justification for Requested Security Clearance form instructions

All requests for security clearances, with the exception of reinvestigations involving the same position titles and designations, require specific justification explaining the need for access to classified national security information as it relates to an individual’s duties. Eligibility for access to classified information shall only be granted based on a demonstrated, foreseeable need for access. All requests for interim security clearances must state the nature of the official functions that require access to classified information or facilities, which must be performed before completion of the investigative and adjudicative process.


Requests such as “…requires a security clearance in the performance of his duties…” without additional detail will not be accepted. All unacceptable requests will be returned for clarification. An appropriate and specific justification for access to classified information should clearly state:


  1. The level of clearance required

  2. The specific duties that require access to classified information

  3. Include where the access will occur and the frequency of access



Employees requiring access to TS/SCI must provide detailed information to the following questions:


  1. What SCI compartments are needed for this position? Compartments must be listed.

  2. On what will you be working that requires SCI access?

  3. With whom will you be interacting?

  4. What type of documents will you need to review?

  5. What systems will you access?

  6. What other relevant information can you provide regarding the need for SCI access as it relates to your duties and your agencies mission?

In addition, all SCI requests MUST be endorsed by the individual’s Under Secretary, Assistant Secretary, or Staff Office Director. This requirement was stated in the “Sensitive Compartmented Information (SCI) Access and Responsibilities” memo dated 6/1/07 that was distributed to all HR offices. If you have any questions, or if you need further assistance, please contact John Loveless, Chief, Personnel Security Branch, at 202/720-0540.




NOTICE: The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Your SSN is needed to keep records accurate because other people many have the same name and birth date. Your SSN will be used to identify you precisely when it is necessary to 1) certify that you need to have access as indicated above or 2) determine that your access to such information is no longer needed. Although disclosure of your SSN is not mandatory, your failure to do so may impede the processing of such certifications or determinations, or possibly result in the denial of your being granted access to classified information.




Form AD-1188 (8/09)

Page


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