Personnel Screening Interview Questionnaire

PERSONNEL SCREENING INTERVIEW QUESTIONNAIRE

Full Name/Rank: / SSN:

1. Effective 25 April 2014, thisPersonnel Screening Interview Questionnaire will be used in determining the acceptability of an individual’s eligibility for continued access to Sensitive Compartmented Information (SCI). It is prescribed by DoDM 5105.21-V3, "Sensitive Compartmented Information (SCI) Administrative Security Manual; Administration of Personnel Security, Industrial Security, and Special Activities; DoD 5200.2R, "Personnel Security Program" and ICD 704, Personnel Security Standards and Procedures Governing Eligibility for Access to Sensitive Compartmented Information and Other Controlled Access Program Information.

2. SCI pre-screening interviews are conducted when there is no current investigative information available to make an adjudicative determination of eligibility for access to SCI.

3. Any information developed during this interview will be made available only to those authorities involved in processing your nomination, those conducting the SSBI, and those adjudicating your investigation for an eligibility determination, or as otherwise authorized by Executive Order or Statute.

4. The Privacy Act of 1974 requires you be informed that Executive Orders 10450, “Security Requirements for Government Employees”, 12958, “Classified National Security Information”, and 12968, “Access to Classified Information” are the authorities for soliciting information during this interview. Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons, is the authority to ask you to provide your Social Security Account Number (SSAN).

I understand the purpose of this SCI Pre-Screening interview and elect to proceed/decline.

____________

(Signature of Interviewee)(Date)

PERSONNEL SCREENING INTERVIEW QUESTIONNAIRE Cont’d

The purpose of this interview is to assure that you continue to meet the standards for access to SCI in accordance with Intelligence Community Directive 704. “All yes answers require a full narrative explanation. If you decline to provide such explanation, this may slow the adjudicative process and delay your access to SCI.”

1. Has your marital status changed since you completed your SF 86; have you married or divorced, or begun cohabitating?

2. Are any members of your immediate family non U.S. citizens?

3. Do you or anyone in your immediate family claim a dual citizenship with another country?

4. Have you visited any foreign countries since you completed your SF 86? If so, please provide the dates, the countries visited and the reason for the visits.

5. Have you consulted with a mental health professional since you completed your SF 86? Was this court ordered or based on violence on member’s part? If yes, please explain.

6. Have you been arrested since your last investigation? If yes, please explain.

7. Have you ever had any adverse involvement with alcohol (e.g., DUI, alcohol treatment, drunk in public, accident where alcohol was a factor)? If so, please explain.

8. Have you used illegal drugs or illicit substances since you completed your last SF 86? If yes, please explain.

9. Have you had a clearance suspended, denied, or revoked since your last investigation or in the last seven years? If yes, please explain.

10. Have you had any bills referred to a collection agency since you last completed an SF 86? If yes, please explain.

11. Have your wages been garnished, have you had any vehicles repossessed, have any tax liens been placed against you, or have you filed bankruptcy? If so, please explain.