DOe F 473.3 Clearance Access Request

DOE F473.3
(8/2017)
(All other versions are obsolete)

U.S. Department of Energy Clearance Access Request
(Form becomes Official Use Only when filled in)

DOE Number (if known)

Submitting SON

CPSO

OMB Control No. 1910-1800
OMB Burden Disclosure
Statement on Reverse

Primary Program Office Code(s) (i.e., EM, FE, IF, OE, SC, etc.) (If known)
Subject Information - All items in this section are mandatory

Employee
email

Employee Type

Employee Phone
SSN

Name (Last, First, Middle, Suffix)

Date of Birth

Place of Birth (City, County, State (or Country if not U.S.))
Citizenship

Dual Citizenship Country (if applicable)

Dual Citizen?

Additional Dual Citizenship Country (if applicable)

Job Title

Work Location
If individual is a Contractor Incumbent, Contractor Applicant, or Contractor Consultant, complete applicable items

Prime Contract Company

If Subcontractor, Company Name

Prime Contract
Number

Sub Contractor Contract
Number (if applicable)

Prime Contract Expiration
Date

Sub-Contract Expiration Date
(if applicable)

Employing
Company Facility
Security Officer
POC & Phone

Employer Code
Facility Code

Is Subject a KMP?

Clearance, Access, and Justification - All items in this section are mandatory

Action Requested

Current Clearance Level of Subject

Current Clearance Required

Will Subject be submitted for a SAP?
Justification: Provide detailed information (without revealing classified data) as to why the Subject requires access. This description must include a
full explanation of the information to be accessed, frequency of access, and for what programs/projects the information is needed.

To be filled out by the Cognizant Personnel Security Office receiving the completed Clearance Access Request Form
May be exempt from public release under the Freedom of Information Act (5 U.S.C. 552). Department of Energy review required before public release.
Exemption number
& category

Name/Org
Guidance (if applicable)

Date

Documents: (Check all that apply and forward to DOE Personnel Security.) (Request will not be processed until all checked Documents are received)
Per DOE O 472.2, Attachment 2, paragraph 2.a. - 2.f: All initial security clearance requests (to include requests for reinstatements and reapprovals) must
include the justification, as set forth above, and all boldfaced items (except in cases where reciprocity applies, as indicated by an '*'):
Proof of Negative Drug Screen Results: Results of drug test within 60 calendar days of the individual's e-QIP signature or, for cases being
considered under reciprocity, within 60 calendar days of the date of the security clearance request (not required for state or local governments)
*e-QIP: A complete e-QIP submission which indicates no illegal use of controlled substances for at least 12 months preceding the individual's
signature.
*Fingerprints: Fingerprints taken electronically via an approved capture method (e.g., at a GSA-provided HSPD-12 enrollment center) (not
required if a previous investigation included a classifiable fingerprint search by FBI).
*Resume or OF 612, Optional Application for Federal Employment: Federal Applicants and Employees Only.
DOE F 5631.18, Security Acknowledgment
*Fair Credit Reporting Disclosure and Authorization: A completed fair credit reporting disclosure authorization, compliant with the Fair Credit
Reporting Act, codified at 15 U.S.C. s1681 et seq. and approved for use by the Director (once obtained, this authorization may be used by DOE for
conducting credit checks directly with consumer agencies as part of its personnel security program.
Other (i.e., Birth Certificate, Certificate of Naturalization, Reinvestigation documentation, etc.)(Specify below)

Certifications (as applicable)
By signing below I hereby certify the individual listed in this request is required to possess a security clearance at the level indicated and that
the job, duties, access areas, and classified information access listed are an accurate description of the individual's position.
Requesting
Official/Supervisor
Signature

Requesting Official/
Supervisor Name/Title/Phone

Contractor Certifying Official
Signature

Contractor Certifying
Official Name/Title/Phone

Federal Certifying
Official Signature

Federal Certifying Official
Name/Title/Phone

Date Clearance Access Request forwarded to DOE Personnel Security

DOE Personnel
Security Signature

DOE Personnel Security
Official Title/Phone

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office
of Management, MA-90, GTN, Paperwork Reduction Project (1910-1800), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC
20585-1290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-1800), Washington, DC 20503.
PRIVACY ACT STATEMENT
Collection of the information requested is authorized by the Atomic Energy Act of 1954, as amended, and by Executive Orders 13764, 10865, and
13526. Disclosure of the information on this form is voluntary; however, your decision not to complete this form could result in a delay in (or denial
of)processing this request (or any future request for reinstatement) of your U.S. Department of Energy (DOE) access authorization/security clearance.
Your DOE access authorization/security clearance can be terminated regardless of whether this form is completed. Your name and Social Security
Number are used as identifying factors to establish and maintain records of DOE access authorization actions in the DOE System of Records, DOE-43,
“Personnel Security Files,” and this form will be completed and maintained in your DOE Personnel Security File. Access to this record, within DOE and by
other individuals, is permitted in accordance with the Privacy Act of 1974, as amended, 10 CFR Part 1008, and for routine uses in System of Records,
DOE-43,
“Personnel Security Files.”

Instructions
CPSO: Use the drop-down list to select the appropriate Cognizant Personnel
Security Office that is responsible for security clearance processing.
Submitting SON: Enter the Submitting Office Number identifier of the office
submitting the request.
DOE Number: Enter Subject's DOE Number, if known or applicable.
Primary Program Code: Enter the code for the primary program to which
Subject will be assigned, if known.
Subject Information - All items in this section are mandatory:
Employee Type: Use the drop-down list to choose the appropriate employee
type for individual.
Employee email: Enter the employee's primary email address.
Employee Phone: Enter employee's primary phone.
Name: Enter individual's full legal name, including full middle name.

Clearance, Access, and Justification - All items in this section are
mandatory
Action Requested: Use drop-down list to select appropriate action
being requested.
Current Clearance Level of Subject: Use the drop-down list to select
the Subject's current clearance level. If the Subject does not currently
have a clearance, select Uncleared.
Clearance Level Required: Use the drop-down list to select the
clearance level required for Subject to preform their duties.
Will Subject be submitted for a SAP: Use the drop-down list to select
Yes or No.
Justification: Per DOE Order 472.2, Attachment 2, paragraph 1.i.: "A
detailed description (without revealing classified information) as to
why the individual requires access. The description must include a full
explanation of the information to be accessed, how often the access is
needed, and for what programs/projects the information is needed."
Insufficient justification will be cause for rejection of request.

SSN: Enter the individual's full Social Security Number
Date of Birth: Use the calendar to select the Subject's date of birth, or manually
enter in DD/MM/YYYY format.

Exemption Section
To be filled out by the Cognizant Personnel Security Office
receiving the completed Clearance Access Request Form

Place of Birth: Enter city, county, state (or country if not U.S.) where Subject was
Documents Required
Check all that apply. Request will not be processed until all checked
born.
enclosures are received. Per DOE O 472.2, Attachment 2, paragraph
2.a. - 2.f: All initial security clearance requests (to include requests for
Citizenship: Choose appropriate country of individual's citizenship.
reinstatements and reapprovals) must include the justification, as set
forth above, and all boldfaced items (except in cases where reciprocity
Dual Citizen: Use drop-down to select Yes or No. If Yes, then use drop-down
applies, as indicated by an '*').
lists to complete Dual Citizenship Country fields as applicable.
Job Title: Enter the Subject's job title.

Certifications (as applicable)
NOTE: If signers have a PIV, then electronic signature is requested.

Work Location: Enter location where Subject will work.
If individual is a Contractor Incumbent, Contractor Applicant, or Contractor
Consultant, complete applicable items
Prime Contract Company: Enter the prime contractor company's name.

Requesting Official: Person completing the request. This can be the
person responsible for submitting the contractor requests, or if Subject
is a Federal Applicant/Incumbent, then this can be the Supervisor, HC
representative, office director, etc.

If Subcontractor, Company Name: Complete if individual works for one of the Contractor Certifying Official: The Certifying Official is responsible
sub-contractors.
for certifying the clearance is required per all applicable laws, rules and
regulations.
Employing Company Facility Security Office POC & Phone: Enter the Facility
Federal Certifying Official: This can be the COR, COTR, or their
Security Office information for the company which employs the Subject.
designee for contractor positions. If local processes require Site
Facility Code: Enter the employing company's Facility Code.
Manager or other federal certifying official to approve the clearance
access request, this is where this person signs. HSO (DOE HQ ONLY)
Employer Code: Enter employing company's Employer Code.
signs here if the request will be processed by DOE Headquarters
Personnel Security.
Contract Number: Enter the contract number for the Prime Contract.
Date Clearance Access Request forwarded to DOE Personnel
Sub Contractor Contract Number (if applicable: If individual works a
Security: Use calendar to select the date the clearance access request
subcontractor, enter the Sub-contract number.
is sent to the appropriate CPSO, or manually enter date in
DD/MM/YYYY format.
Contract Expiration Date: Use the Calendar to select the date the Prime
contract expires, or manually enter in DD/MM/YYYY format.
Sub-Contract Expiration Date (if applicable): If applicable, enter the
expiration date of the sub-contract, or manually enter date in DD/MM/YYYY
format.
Is Subject a KMP?: Use drop-down list to select Yes or No to indicate if Subject
is a Key Management Person for the company.