Security Pre-Screen Questionnaire

Personal Information

Name

First

Middle

Last

Layout

Personal Email Address

Best cell phone number to reach you

Layout

Place of Birth

City, State & Country

Born Overseas?

If born overseas, please provide details

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Citizenship Information

1. Are you a United States Citizen?

Yes
No

2. Are all members of your immediate family (including spouse, children, parents, parents-in-law, cohabitants, half and step relations, or any person to whom you have close ties of affection or obligation) United States citizens?

Yes
No

Provide further details (2):

3. Are any of the individuals mentioned above dual citizens of the United States and another country?

Yes
No

Provide further details (3):

Foreign Contacts/Foreign Activities

4. Do you have any close and/or continuing contact with citizens of another country?

Yes
No

Provide further details (4):

5. Do you have any foreign property, business connections, or foreign financial interests or assets?

Yes
No

Provide further details (5):

Employment Record

6. Have you ever had any incidents involving misconduct or negligence reported by an employer that resulted in you receiving a written or verbal warning, security incident, resignation by mutual consent or termination?

Yes
No

Provide further details (6):

7. Have you been fired from a job?

Yes
No

8. Have you left a job by mutual agreement following allegations of misconduct?

Yes
No

9. Have you left a job by mutual agreement following allegations of unsatisfactory performance?

Yes
No

10. Have you left a job for other under unfavorable circumstances?

Yes
No

Clearance/Access

11. Have you ever held a U.S. Government security clearance?

Yes
No

What Level of Clearance (11)?

Secret
Top Secret

Date of Last Completed Background Investigation (11):

12. Do you currently have or have you ever had a Sensitive Compartmented Information (SCI) access?

Yes
No

What Agency granted the eligibility (12):

Dates SCI access was held (12):

What Level of Clearance (12)?

SI
SI/TK

13. Have you ever taken a polygraph as part of security clearance processing?

Yes
No

Provide the following CI Date, Agency, Lifestyle/Full Scope Date, Agency (13):

14. Do you have an active green community badge?

Yes
No

15. Have you ever had a security clearance or access denied, suspended, placed on inactive or revoked?

Yes
No

16. In the past twelve months have you had a security clearance crossover denied or delayed?

Yes
No

Illegal use of drugs and use of alcohol

17. Have you EVER used or sold any illegal narcotics?

Yes
No

Provide explanation (17):

Have you previously reported this information to the Government or your Security Office? (17)

Yes
No
N/A

18. Has your use of alcohol had a negative impact on your work performance or resulted in intervention by law enforcement/public safety personnel?

Yes
No

Provide explanation (18):

Have you previously reported this information to the Government or your Security Office? (18)

Yes
No
N/A

Financial Record

19. Have you filed a petition under any chapter of the bankruptcy code (to include Chapter 13)?

Yes
No

Was this previously reported to the Government or your Security Office? (19)

Yes
No
N/A

20. Do you currently have any debts that are greater than 90 days past due?

Yes
No

21. The agency may require a credit check upon security processing. Are you willing to consent to a credit check if required?

Yes
No

IT Authorization

22. Have you ever illegally or without proper authorization entered into any Information Technology (IT) system?

Yes
No

23. Have you ever illegally or without authorization modified, destroyed, or manipulated access to information residing on an IT system?

Yes
No

24. Have you ever introduced, removed, or used hardware, software, or media in connection with any IT systems without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations?

Yes
No

Attestation

25. Do you have any reason to believe your processing for an NSA clearance would not be successful?

Yes
No

Provide explanation (25):

By submitting this form, you are certifying the information provided is made in good faith and is true, complete and correct to the best of your knowledge and belief. You understand any false statement, misrepresentation, or omission of material fact may result in the withdrawal of sponsorship for clearance/access or termination of employment.

Personnel Security Pre-screen Questionnaire