Form TSA Form 2211 TSA Form 2211 SSI Access Threat Assessment Questionnaire

SSI Access Threat Assessment Questionnaire
INSTRUCTIONS: Please print or type the required information requested below for consideration of
your TSA sensitive security information (SSI) access request. Please bring the completed form with you
when you submit your fingerprints, location to be determined by TSA. Complete Section 3 by selecting
the appropriate responses and providing any required additional details on a separate page for submission
with your completed access questionnaire. Please reference the corresponding number for the Section 3
question that you are addressing by marking your response with that number.

SECTION 1 – CONTACT INFORMATION
Full Legal Name (Last, First, Middle)
Aliases and/or Prior Names, if any
Name of Employer
Work Address (Street, City, State, Zip Code)
Mailing Address (Street, City, State, Zip Code), if different from Work Address
Email Address, if email correspondence is preferred

SECTION 2 – PERSONAL INFORMATION

Residential Address (Street, City, State, Zip Code), if different from Mailing Address.
Male
Female
Gender
Date of Birth (mmddyyyy)
Place of Birth (Country)

Country of Citizenship

Alien Registration No., if applicable

Residential Phone No.

-

-

Social Security No. (voluntary)

Non-Immigrant Visa No., if applicable

Passport Country and No.: This information is voluntary and may expedite the adjudication process for applicants who are
U.S. citizens born abroad.

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TSA Form 2211, December 2006

OMB control number 1652-0042; expiration date 7/31/2007

SSI Access Threat Assessment Questionnaire

SECTION 3 – ADDITIONAL QUESTIONS
Attorney Applicants Only:
1.

Yes

No

Are you, and have you always been, in good standing with every bar to which you
are, or have been, a member? If ‘No’, please provide a detailed explanation on a
separate piece of paper.

2.

Yes

No

Have you ever been denied admission to any bar? If ‘Yes’, please provide a detailed
explanation on a separate piece of paper.

3.

Yes

No

Have you ever been disciplined, admonished, suspended, disbarred or otherwise
sanctioned by or from any bar of which you are, or have been, a member? If ‘Yes’,
please describe on a separate piece of paper each such incident, even if the sanction
later was withdrawn, suspended or modified.

4.

Yes

No

Has any person or entity, while represented by you, ever been held in contempt for
violating a confidentiality or protective order in a judicial or administrative
proceeding? If ‘Yes’, please describe on a separate piece of paper each such incident,
even if the citation later was withdrawn, suspended or modified.

5.

Yes

No

Has any person or entity, while represented by you, ever been sanctioned as a result
of conduct related to a judicial or administrative proceeding? If ‘Yes’, please
describe on a separate piece of paper each such incident, even if the sanction later was
withdrawn, suspended or modified.

Court Reporter Applicants Only:
6.

Yes

No

Are you currently listed on the registry of the National Court Reporters Association,
or have you passed an equivalent qualifying examination? If ‘Yes’, please specify the
registri(es) on a separate piece of paper.

7.

Yes

No

Do you currently hold a clearance for access to classified national security
information under Executive Order No. 12958? If ‘Yes’, please specify on a separate
piece of paper the level of the clearance and the agency that granted it.

8.

Yes

No

Have you ever been denied any type of security-related clearance with the Federal
government? If ‘Yes’, please provide a detailed explanation on a separate piece of
paper.

9.

Yes

No

Have you ever been disciplined or terminated for the mishandling of information? If
‘Yes’, please provide a detailed explanation on a separate piece of paper.
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TSA Form 2211, December 2006

OMB control number 1652-0042; expiration date 7/31/2007

SSI Access Threat Assessment Questionnaire

All Applicants:
10.

Yes

No

Have you ever been held in contempt for violating a confidentiality or protective
order in a judicial or administrative proceeding? If ‘Yes’, please describe on a
separate piece of paper each such incident, even if the citation later was withdrawn,
suspended or modified.

11.

Yes

No

Have you ever been sanctioned as a result of conduct related to a judicial or
administrative proceeding? If ‘Yes’, please describe on a separate piece of paper
each such incident, even if the sanction later was withdrawn, suspended or modified.

12.

Yes

No

Do you agree to abide by the TSA instructions concerning the handling of SSI in
connection with this proceeding in the absence of any contrary ruling by the Court?

Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and
correct.
Executed on: ________________

Signature: ___________________

Should I seek judicial review of TSA’s final decision on my threat assessment, I authorize TSA to
release the foregoing and any other information related to my threat assessment to the court(s)
presiding over that review.
Executed on: ________________

Signature: ___________________

PRIVACY ACT NOTICE: Authority: 49 U.S.C. §114 authorizes the collection of this information. Purpose: TSA will use
this information to conduct a threat assessment on individuals who seek access to Sensitive Security Information (SSI) for use
in a civil proceeding in federal court. Routine Uses: The information will be used by and disclosed to DHS personnel and
contractors or other agents who need the information to assist in activities related to transportation security. Additionally, DHS
may share the information with law enforcement, intelligence, or other government agencies as necessary to identify and
respond to potential or actual threats to transportation security, or pursuant to its published Privacy Act system of records notice
(SORN), DHS/TSA 002, Transportation Security Threat Assessment System (T-STAS). This SORN was last published in the
Federal Register on November 8, 2005, and can be found at 70 FR 67731- 67735. Disclosure: Furnishing this information is
voluntary. However, failure to furnish the requested information may delay or prevent the completion of your security threat
assessment, without which you may not be granted access to SSI. Providing your Social Security Number is voluntary, but
failure to provide it may result in a delay in processing your threat assessment.
PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: TSA is collecting this information to conduct
a threat assessment to determine your eligibility to gain access to Sensitive Security Information (SSI) for use in connection
with a federal civil court proceeding. This is a voluntary collection of information, but failure to provide the information may
result in an inability to approve your eligibility to gain access to SSI for use in connection with a federal civil court proceeding.
TSA estimates that the total average burden per response associated with this collection is approximately one hour. If you have
any comments regarding this form, you may write to TSA, Office of Chief Counsel, TSA-2, 601 S. 12th Street, Arlington, VA,
22202. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number. The control number assigned to this collection is OMB 1652-0042, which expires
7/31/2007.
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TSA Form 2211, December 2006

OMB control number 1652-0042; expiration date 7/31/2007