Personnel Security Prescreen Questionnaire Security Prescreen Questionnaire I understand that this Personnel Security Prescreen Questionnaire and the information provided by me herein

• Complete the Prescreen Questionnaire in its entirety as soon as possible.• Include your full name and today’s date in the space provided.• When completed, return the form to SAIC Security via fax number (256) 971-6575

or hand-deliver to SAIC Security personnel.• Do not forward or otherwise share this form with anyone who is not SAIC Security.• Do not send form by unencrypted email as it contains Personally Identifiable

Information (PII).• Do not provide classified information.• If additional space is needed to answer any questions, use the Addendum Space at

the end of this Questionnaire.

Personnel Security Prescreen Questionnaire

SAIC Employee

Company Name:

Contractor/Consultant

Applicant’s Name (Last, First Middle):

Today’s Date:

Applicant Type:

Revised 10/24/17 page 1 of 9 Last Name:

SAIC Security Use Only

JPAS:

SC :

Job Req#:

Requisition Number:

SAIC SECURITY - INTERNAL USE ONLY

I DeclineI Accept

Personnel Security Prescreen Questionnaire SAIC SECURITY - INTERNAL USE ONLY

I understand that this Personnel Security Prescreen Questionnaire and the information provided by me herein will be used by SAIC only for security-related purposes consistent with applicable laws, regulations and policies. I acknowledge and consent to SAIC using the information I provide in the Questionnaire to determine my eligibility for or to verify my U.S. Government security clearance, and/or to confirm, including on an on-going basis if I am hired by SAIC, my continuing eligibility to access classified, national security-related and other sensitive information.

I further understand that the U.S. Government may require me to undergo a government polygraph examination and/or complete a background investigation. I understand these national security requirements, and consent to them, knowing that such examinations or background investigations may not necessarily result in the U.S. Government granting me a security clearance or approving my access to classified or other sensitive information. I understand that SAIC does not control government decisions such as these regarding security clearances or approvals to access classified or other sensitive information. In addition, I understand that SAIC, the U.S. Government and other SAIC customers or business partners participate in certain Continuous Evaluation (CE) activities to determine ongoing eligibility for access to classified and other sensitive information. I consent to monitoring on a continuous basis of certain data that are relevant to U.S. national security concerns, including my eligibility to access classified and sensitive information.

I agree to hold SAIC or its subsidiaries, as well as their employees, agents, representatives, directors, and affiliates harmless from and waive any claims, including for damages, losses, liabilities, expenses and other costs (such as attorney and legal fees) or any other charge or complaint filed, arising from the disclosing, retrieving, reporting and use of the information contained in this questionnaire for the purposes described above.

I certify that the entries made by me on the Personnel Security Prescreen Questionnaire are true, complete, and accurate to the best of my knowledge and belief and are made in good faith and voluntarily. I understand intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my security cleamnce, employment prospects, or job status, up to and including denial or revocation of my security clearance by the government and termination of SAIC. I also certify that the answers provided on this form will be consistent with information that will be provided on any additional forms required by SAIC to include, but not limited to, the SF-86. I also acknowledge that I have a right to decline to complete the Personnel Security Prescreen Questionnaire information, but if I decline such action will significantly impact my ability to be offered a position with SAIC. Moreover, I understand and agree that if I am hired and I provided inconsistent, inaccurate or incomplete information, such conduct may result in disciplinary action up to and including termination.

*Information regarding your date and place of birth will be used for security purposes only and will not be a factor inany employment decisions.

Consent & Waiver

printed name (last , first middle )

signature date

page 2 of 9 Last Name:

5.T ype: CI FS

6. Are you now, or have you ever been, a member of the Armed Forces?

If yes, provide:

a. Branch of Service:b. Current Status:

1. Have you ever been processed for a security clearance?

If yes, provide:a. Type of security clearance (i.e. Secret, Top Secret, TS/SCI, etc.):b. Name of the agency that processed/granted the clearance:c. Approximate date of most recent background investigation:d. Are you currently briefed in access?e. If debriefed, provide approximate debrief date:

2. Have you ever had a securivty clearance denied, suspended or revoked?

If yes, provide:

a. Approximate Date:b. Agency:c. Explain:

3. Do you have any security clearance or inspector general investigations in-progress?

If yes, provide:

a. Approximate Date:b. Agency:c. Explain:

4. Have you ever successfully completed a polygraph examination?

If yes, provide:

a. The type of polygraph that was administered: b. Approximate date of most recent polygraph:c. Agency that administered the exam:

c. Type of Discharge: Active Duty Active Reserve Duty Retired Separated Terminal Leave Honorable Dishonorable General Discharged. Separation/Retirement/Terminal Leave Date:

If no, and you are a male born after December 31, 1959, have you registered for the Selective Service?

YES NO

page 3 of 9

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

applicant’s full name (last , first middle)

social security number

place of birth

email addresswork phone

maiden name/aliases used since your 18th birthday

date of birth (mm/dd/yyyy)

primary phone

mailing address (including zip code)

Last Name:


1.

CI FS

7. Are you a U.S. Citizen?

If no, please provide country(ies) of citizenship:8. Do you currently hold, or have ever held, dual/multiple citizenship?

If yes, provide country(ies) of citizenship:a. Are you willing to renounce your foreign citizenship?b. Have you ever been issued a passport (or identity card for travel) by a countryother than the U.S.?

9. Do you have members of your immediate family (spouse, children, siblings, parents, or in-laws) who are non - U.S. citizens?If yes, provide:

a. Relationship:b. Country(ies) of citizenship:c. Currently resides in the U.S.?

(use the addendum space for additional family members)

10. Do you have any foreign-born adults living with you?

If yes, provide:

a. Place of birth for each person:b. Country(ies) of citizenship:

11.Do you have a close or continuing relationship with a foreign national (i.e. non-U.S.

citizen neighbors, friends, Au Pair, Nanny, etc.)?

If yes, provide:

a. Relationship:b. Country(ies) of citizenship:

(use the addendum space for additional information)

12.Do you, your spouse, or immediate family members have any foreign financial interests

to include real estate or bank accounts?

If yes, explain:

13.Have you, your spouse, or immediate family members received any educational, medical,

retirement, social welfare, or other such benefit from a foreign country?

If yes, explain:

14.Have you ever provided financial support to any foreign national?

If yes, explain:a. Nature of Relationship:b. Frequency of Support:c. Country(ies) of citizenship:

Are you willing to relinquish your foreign passport?

page 4 of 9

YES NO

YES NO

YES NOYES NO

YES NOYES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Last Name:


15.Have you ever sponsored any foreign national to come to the U.S. as a student, for work,

or for permanent residence?If yes, provide:

a. Place of Birth:b. Purpose of Sponsorship:

16.Have you ever served as a civilian or military member in a foreign country’s defense force

or Government agency (foreign military, intelligence, diplomatic, security forces, or

militia)?If yes, provide:

a. Name of foreign organization and country:b. Dates of Service:c. Any contact information you maintain with current or former associates:

17.Have you ever had any contact with a representative of a foreign Government or an

intelligence officer of a non - U.S. agency that was not for official business for the U.S.

Government (do not provide classified information)?

If yes, explain:

18.Have you attended or participated in any conferences, trade shows, seminars, or meetings

outside the U.S. that was not on official business for the U.S. Government?

If yes, provide:a. Name of event:b. Description of event:c. City and country of event:

19.In the past ten (10) years, have you traveled to a foreign country?

Did any unusual events occur while you were on foreign travel?

If you answered “YES” to any of the above questions (8-19) and you held/hold a security

clearance, was it previously reported to the U.S. Government or your security office?

In the past ten (10) years and regardless of disposition:

20.Have you been issued a summons, citation, or ticket to appear in court in a criminal

proceeding (exclude traffic citation fines less than $300)?

21.Have you been arrested by any type of law enforcement official?

22.Have you been part of any civil court proceedings?

23.Have you been charged, convicted or sentenced of a crime in any court to include

domestic violence?

24.Have you been or are you currently on probation or parole?

25.Are you currently on trial or awaiting trial on criminal charges?

YES NO

YES NO

YES NO

YES NOYES NO

YES NO

YES NO

YES NO

YES NOYES NO

YES NOYES NO

page 5 of 9

YES NO

Last Name:


If you answered “YES” to any question above (20-25), provide information for each and every offense:

a. Date:b. Type of incident:c. Details:


Have you ever and regardless of disposition:

26. Been charged with a felony, misdemeanor or UCMJ offense?

27. Been charged with a firearms or explosives offense?

28. Been charged with any offense(s) related to alcohol or drugs?

If you answered “YES” to any question above (26-28), provide information for each and every offense:

a. Date:b. Type of incident:c. Details:


Within the last ten (10) years:

29.Has your use of alcohol had a negative impact on your work performance, your

professional or personal relationships, your finances, or resulted in intervention by

law enforcement or public safety personnel?

If yes, explain:

30. Have you illegally used any controlled substance or prescription drugs?

Include marijuana even if used in a state where it is legalized.

If yes, provide the following:

d. Disposition still pending?

d. Disposition still pending?

e. Final disposition date:

e. Final disposition date:

type frequency most recent date while holding a clearance ?ex. marijuana 1 time provide yes or nonov 2010

page 6 of 9

YES NO

YES NOYES NOYES NO

YES NO

YES NO

YES NO

Last Name:


Within the last ten (10) years:

31. Have you consulted with a health care professional regarding any emotional or mental

health condition or were you hospitalized for any such condition?

Answer ‘No’ if the counseling was for any of the following reasons and was

not court-ordered:

• Strictly marital, family, or grief not related to violence by you; or

• Strictly related to adjustments from service in a military combat environment; or

• You were the victim of a sexual assault and consulted with a health care professional

regarding an emotional or mental health condition during this period strictly in

relation to the sexual assault.

If yes, explain:

32.Have you been more than 120 days delinquent on any financial obligation?

If yes:

a. Have you taken any action to bring current?33.Have you had any debt placed in collections?

If yes, provide:

a. Amount (USD) owed: $b. Was it satisfied?If yes, provide a date:

34.Have you defaulted on a loan (i.e. student loans, personal, mortgage, etc.), declared

bankruptcy, had judgements entered against you or had personal property repossessed?

If yes, provide:

a. If you defaulted on a loan,Amount (USD) owed: $

b. If bankruptcy was filed, has it been discharged?Discharge date:

c. If personal property was repossessed,Amount (USD) owed: $

35.Have you been subject to a tax lien or wage garnishment, regardless of the

reason or final outcome?

If yes, explain:

36 . Have you failed to file or pay federal, state or local taxes and/or are you currently

delinquent on any of these taxes?

If yes, provide:

a. Amount (USD) owed: $

page 7 of 9

YES NO

YES NO

YES NOYES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Last Name:


37. Have you been late or are you currently delinquent on any child support payments?

If yes, provide:

a. The amount (USD) you are in arrears/overdue: $38.Have you ever experienced financial problems due to gambling?

If yes, provide:

a. Amount (USD) owed: $

If you answered YES to any questions above (20-38) and you held/hold a security clearance,

was it previously reported to the U.S. Government or your security office?

39.In the last ten (10) years, have you illegally or without proper authorization:

a. Accessed or attempted to access any information technology (IT) system?b. Modified, destroyed, manipulated, or denied others access to information

residing on an IT system?c. Introduced, removed or used hardware, software or media in connection with

any IT system when specifically prohibited by rules, procedures, guidelinesor regulations?

If yes, explain:

40.Have any of the following situations occurred regarding your employment:

a. Termination?b. Quit a job after being told you would be terminated?c. Left a job by mutual agreement following allegations of misconduct?d. Left a job by mutual agreement following allegations of

unsatisfactory performance?e. Left a job for other reasons under unfavorable circumstances?

If yes, explain:

41.Have you had any security incidents or violations that could have resulted in the possible

or actual compromise of classified information?

a. Date:b. Nature:c. Actions taken as a result of this incident:

If you answered YES to any questions above (39-41) and you held/hold a security clearance,

was it previously reported to the U.S. Government or your security office?

page 8 of 9

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NOYES NOYES NO

YES NO

YES NO

YES NO

YES NO

Last Name:


42.If you currently hold an active security clearance, has any information changed since

you last reported it on an SF-86 or eQIP?

If yes, list the changes:

43. Is there anything that has not been covered in the above questions you feel is pertinent

to discuss or which may preclude you from obtaining or transferring a clearance/access?

If yes, explain:

page 9 of 9

For additional explanations, please use this addendum space. Be sure to reference your question number and letter when providing additional information.

Ex: Question 4b:

Addendum Space

YES NO

YES NO

Last Name:


Personnel Security Prescreen Questionnaire Security Prescreen Questionnaire I understand that this Personnel Security Prescreen Questionnaire and the information provided by me herein

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