REQUEST FOR INFORMATION

I. FACILITY (Instructions: complete each section below. Use the TAB key to move from field to field)
a. Facility Name: / b. CAGE Code:
c. AKA, DBA, TA: / N/A / d. FCL Level: / Select OneConfidentialSecretTop Secret
e. Physical Address: / f. FCL Date:
g. Mailing Address:
h. Main Phone Number:
i. Internet Address:
j. Type of Business
(Select one (1) that closest describes your facility) / Accounting
Alarm (Central Station)
Alternate Storage Facility
Architectural
Building Management
CRAF Program
College/University
Commercial Carrier
Construction
Consulting
Courier Service
Custodial Services
Design & Manufacturing
Engineering
Explosives/Ordnance
Freight Forwarder
Graphic Arts/Video/Digital Productions
Guard/Security Services
Holding Company / Information Systems & Services
Law Firm
Manufacturing
Marketing/Liaison
Patent Attorney
Manufacturing
Professional Association
Professional Employer Organization (PEO)
Professional Services
Research & Development
Sealift Programs
Services
Shipbuilding, Maintenance & Repair
Software Engineering
Telecommunications
Temporary Help Supplier
Translation Services
Transportation
Verbatim Reporting
k. Principal Product/Service:
l. FOCI Restrictions: / Select OneNoneBoard ResolutionVoting Trust AgreementProxy AgreementSpecial Security Agreement (SSA)Security Control Agreement (SCA)Limited FCL
m. Cleared off-sites: / None
II. LEGAL STRUCTURE
Business Structure: / Corporation / LLC / Sole Proprietorship / Partnership
If a Corporation: / Home Office / Parent / Division / Subsidiary / Joint Venture / None of these
If a Division or Subsidiary, please provide the following information:
a. Name of Home Office or Parent Organization:
b. FCL Level and CAGE Code:
c. Street Address:
d. City, State, Zip Code:
e. POC Name: / POC Title:
g. POC Phone: / POC Email:
III. FACILITY SECURITY OFFICER and SENIOR MANAGEMENT OFFICIAL
a. Facility Security Officer (FSO) Name: / Appointment Date:
b. FSO Office Phone: / ext ? / c. Alt. Phone (Cell): / mobile blackberry
d. FSO Fax:
e. FSO Email Address:
f. Assistant FSO (AFSO):
g. AFSO Office Phone: / ext ? / h. Alt. Phone (Cell): / mobile blackberry
i. AFSO Fax:
j. AFO Email Address:
k. Name of Senior Management Official (See the Facility KMP List):
l. Senior Management Official Office Phone: / ext ?
m. Senior Management Official Fax Phone:
n. Senior Management Official Email Address:
IV. EMPLOYEE CLEARANCE INFORMATION
Please provide the following numbers:* / TS / S / C / Uncleared / TOTAL
a. KMP Employees: / 0 / 0 / 0 / 0 / 0
b. Employees not assigned overseas: / 0 / 0 / 0 / 0 / 0
c. Employees assigned overseas: / 0 / 0 / 0 / 0 / 0
d. Consultants: / 0 / 0 / 0 / 0 / 0
e. Limited Access Authority (LAA): / 0 / 0 / 0 / 0
b. Foreign Persons/US Persons (non U.S. citizens): / 0 / 0
*Include part-time employees / TOTAL / 0 / 0 / 0 / 0 / 0
V. CONTRACTS
Please provide the following: / TS / S / C / TOTAL
a. No. of classified prime contracts awarded to the facility: / 0 / 0 / 0 / 0
b. No. of classified subcontracts awarded to the facility: / 0 / 0 / 0 / 0
c. No. of classified subcontracts the facility awarded: / 0 / 0 / 0 / 0
d. Foreign contracts: / 0
TOTAL / 0 / 0 / 0 / 0 / 0
Customers (Provided total numbers of … :
a. All contracts (include Commercial & Government): / b. All Classified Only: / b. DoD Classified Only:
V. CONTRACTS (cont.)
Please list the user agencies your contracts support and percentage of classified contracts in the following table
(INSTRUCTION: DO NOT USE Acronyms):
User Agency (Government Customer) / 100.00%
SAMPLE: U.S. NAVY / 100%
%
%
%
%
%
%
%
%
VI. CLASSIFIED HOLDINGS / STORAGE
Storage Level (None, Confidential, Secret, or Top Secret) : / Select OneNoneConfidentialSecretTop Secret
Classified Mailing Address:
Please provide the following: / TS / S / C / TOTAL
a. Number of classified documents currently on hand: / 0 / 0 / 0 / 0
b. Number of classified documents waiting for destruction: / 0 / 0 / 0 / 0
c. Number of pieces of classified hardware on hand: / 0 / 0 / 0 / 0
TOTALS / 0 / 0 / 0 / 0
d. Security containers for storing classified material: / 0 / 0 / 0 / 0
e. Closed Areas: / 0 / 0 / 0 / 0
f. Restricted Areas: / 0 / 0 / 0 / 0
VII. CLASSIFIED INFORMATION SYSTEMS (AIS) (Type N/A, if not applicable)
ISSM: / Phone: ext ? / Email:
ISSO: / Phone: ext ? / Email:
Please provide the following: / TS / S / C / TOTAL
a. Cleared AIS (Standalone): / 0 / 0 / 0 / 0
b. Cleared AIS (WAN/LAN): / 0 / 0 / 0 / 0
c. Interconnected Systems: / 0 / 0 / 0 / 0
VIII. COMMUNICATIONS SECURITY (COMSEC) (Type N/A, if not applicable)
COMSEC Custodian: / Phone:
COMSEC Custodian Email: / PCL Level: / Select OneTOP SECRETSECRETCONFIDENTIAL
Alt. COMSEC Custodian: / Phone:
Alt. COMSEC Custodian Email: / PCL Level: / Select OneTOP SECRETSECRETCONFIDENTIAL
Type of Account: / N/ATraditionalSOCA
Account Number:
Number of items on hand:
Date of last NSA audit:
IX. SPECIAL CONSIDERATIONS: Do you have… (Select your answer)
NATO Briefing Requirements? / YesNo if Yes, last briefing was conducted on:
CNWDI Briefing Requirements? / YesNo if Yes, last briefing was conducted on:
COMSEC Briefing Requirements? / YesNo if Yes, last briefing was conducted on:
Is DSS carved out of any of your classified efforts? / YesNo
X. INTERNATIONAL: Do you have… (Type N/A, if not applicable)
Any classified international contracts? / YesNo
Any controlled defense articles and services (subject to the ITAR) that are being provided to a foreign entity, inside or outside the United States? / YesNo
If yes, are the articles or services exchanged through Direct Commercial Sales (DCS), Foreign Military Sales (FMS) or any other non-DCS types of arrangement between a U.S. Government agency and a foreign government agency? / Select OneDirect Commercial Sales (DCS)Foreign Military Sales (FMS)Other non-DCS
If yes, the name of your Export Control Officer (ECO) :
ECO phone number:
ECO email address:
Are you storing any classified Foreign Government Information (FGI)? YesNo


Please additional provide the following information:

1.  Attach a brief overview of your facility involvement in the NISP. (see Overview of NISP Operations (8-2010).doc)

2.  Attach a list of cleared employees assigned overseas by name, clearance level, level of access, date of assignment, address/ location of assignment and associated contract number(s).

3.  Attach a list name, address and telephone number of uncleared locations where cleared employees are assigned. Include the name and personnel clearance level of employees at each location.

Complete the following:

Classified Contracts List

If applicable, …

Complete a list of ACTIVE subcontractor supporting classified efforts (see Subcontracts Awarded List (4-1-2010).doc)

Complete the cleared consultants list (see Cleared Consultants List (8-2010).doc)

Complete the SSP and MSSP IS Tracking Form only if you have information systems (IS) approved to process classified information (see SSP and MSSP IS Tracking Form TemplateJGRev1.xls)

Have ready for the inspection

Originals of the CSA designated forms (DSS 381-R Letter, DD 441, DD 441-1 (if applicable) SF 328 (if applicable)

Most recent KMP list with supporting documentation such as meetings minutes establishing the KMPs.

Security education material and records

Security records on cleared personnel (JPAS and physical files)

Copies of reports regarding adverse information, security infractions, security violations, and suspicious contacts.

DD 254s awarded/received

DD 254s issued

If applicable, list all closed areas, restricted areas, and/or vaults by location and approved level of safeguarding. Attach a copy of DSS Form 147 “Record of Controlled Area” for each closed area.

Last Updated (08/2010)