DOE F 5631.18 Security Acknowledgement

DOE F 5631.18
(11/94/Administrative Update 03/2011)
All Editions Prior to 11/94 Are Obsolete

BOTH SIDES OF THIS FORM MUST BE READ AND SIGNED

OMB Control No.
1910-1800

U.S. DEPARTMENT OF ENERGY

OMB Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average 15 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 the Office of Health,
Safety and Security’s Office of Departmental Personnel Security (HS-1.4), U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington, D.C.
20585; and to the Office of Information and Regulatory Affairs, Office of Management and Budget (OMB), Washington, D.C. 20503.

SECURITY ACKNOWLEDGEMENT
I, ______________________________________________________, make the following statements with the understanding and intent that
my statements will be used by the U.S. Department of Energy (DOE) in meeting its obligation to determine my eligibility for access to
Restricted Data, other classified information, and special nuclear material.
1.

I understand that it is the policy of the DOE to control access to and dissemination of Restricted Data, other classified information, and
special nuclear material.

2.

I understand that, in carrying out the aforesaid policy, the DOE has issued and will issue and revise, as circumstances require, certain
instructions and regulations pertaining to the access to, and control and dissemination of Restricted Data, other classified information,
or special nuclear material.

3.

I shall not reveal to any person any Restricted Data or other classified information, of which I gain knowledge as a result of my
employment, assignment, or duties, except in accordance with official instructions and regulations of the DOE or except as may be
hereafter authorized by officials empowered to grant such authority.

4.

I understand that the provisions of the Atomic Energy Act of 1954, as amended, prescribe penalties for the disclosure of Restricted
Data to unauthorized persons, and the provisions of U.S. Code, Title 18, "Crimes and Criminal Procedures," prescribe penalties for
the disclosure to unauthorized persons of information respecting the national defense, and for loss, destruction or compromise of such
information through gross negligence.

5.

I understand that willful or gross carelessness in revealing or disclosing to any unauthorized person Restricted Data or other classified
matter pertaining to the DOE or any other Government agency may constitute sufficient cause for termination of my association with
classified programs.

6.

I understand that I am to report to the DOE any proposed travel to a sensitive country. Procedures for reporting such travel are
contained in DOE 1500.3, "Foreign Travel Authorization."

7.

I understand that my use of alcohol habitually to excess, and/or my involvement with any illegal drug, could result in the loss of my
DOE access authorization.

8.

I understand that I am to provide to the DOE: within 3 working days, information concerning any legal action to effect a change in my
name; and within 45 working days, a DOE F 5631.34, "Data Report on Spouse," in accordance with the provisions of DOE M 470.4-5,
“Personnel Security."

9.

I understand that I am to notify the DOE directly within 3 working days of all arrests, charges (including charges that are dismissed), or
detentions by Federal, State, or other law enforcement authorities, for any violation of any Federal law, State law, county or municipal
law, regulation or ordinance, other than traffic violations for which a fine of $250 or less was imposed, occurring during any period in
which I may hold DOE access authorization and which occurred subsequent to the completion of the security forms which I executed
on:

Date

Signature

(Place at which Security Acknowledgement is Signed)

Name of Employer

Privacy Act Statement and Clearance Criteria on Reverse
BOTH SIDES OF THIS FORM MUST BE READ AND SIGNED
18 U.S.C. SECTION 1001; ACT OF JUNE 25, 1948; 62 STAT. 749; MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT
OR PRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTERS WITHIN ITS JURISDICTION.

DOE F 5631.18
(11/94/Administrative Update 03/2011)
All Editions Prior to 11/94 Are Obsolete

BOTH SIDES OF THIS FORM MUST BE READ AND SIGNED

OMB Control No.
1910-1800

PRIVACY ACT STATEMENT
Collection of information requested is authorized by the Atomic Energy Act of 1954, as amended, Executive Orders 10450, 10865, and 13526, and U.S.
Department of Energy (DOE) M 470.4-5, “Personnel Security.” The name of the individual is used as an identifying factor to establish and maintain records of
DOE personnel security actions and this form will become part of the individual’s DOE Personnel Security File (PSF) (DOE System of Records DOE-43,
"Personnel Security Clearance Files“). Access to the PSF within the DOE and by other individuals is permitted as stipulated in DOE M 470.4-5 and as listed
as Routine Users in DOE System of Records DOE-43. Disclosure of the information requested on this form is voluntary; however, if the information is not
provided, the request for your DOE access authorization (security clearance) will not be processed. If you possess a DOE access authorization and elect not
to complete this form as required for reinvestigation purposes, your DOE access authorization may be administratively terminated. A copy of this form will be
provided to you upon verbal or written request.

CLEARANCE CRITERIA STATEMENT
I understand that an initial investigation or reinvestigation will be conducted of me at the request of the DOE, the results of which will be used by the DOE to
determine my initial or continuing eligibility for DOE access authorization (security clearance). Further, I understand that the following types of information, as
listed under Title 10, Code of Federal Regulations, Part 710 (specifically Section 710.8), "Criteria and Procedures for Determining Eligibility for Access to
Classified Matter or Special Nuclear Material," may raise a doubt as to my eligibility for DOE access authorization.
Derogatory information shall include, but is not limited to, information that the individual has:
a)

Committed, prepared, or attempted to commit, or aided, abetted, or conspired with another to commit any act of sabotage, espionage, treason,
terrorism, or sedition.

b)

Knowingly established or continued a sympathetic association with a saboteur, spy, terrorist, traitor, seditionist, anarchist, or revolutionist,
espionage agent, or representative of a foreign nation whose interests are inimical to the interests of the United States, its territories or
possessions, or with any person advocating the use of force or violence to overthrow the Government of the United States or any state or
subdivision thereof by unconstitutional means.

c)

Knowingly held membership in or had a knowing affiliation with, or has knowingly taken action which evidences a sympathetic association with the
intent of furthering the aims of, or adhering to, and actively participating in, any foreign or domestic organization, association, movement, group, or
combination of persons which advocates or practices the commission of acts of force or violence to prevent others from exercising their rights under
the Constitution or Laws of the United States or any state or subdivision thereof by unlawful means.

d)

Publicly or privately advocated, or participated in the activities of a group or organization, which has as its goal, revolution by force or violence to
overthrow the Government of the United States by unconstitutional means with the knowledge that it will further those goals.

e)

Parent(s), brother(s), sister(s), spouse, or offspring residing in a nation whose interests may be inimical to the interests of the United States.

f)

Deliberately misrepresented, falsified, or omitted significant information from a Personnel Security Questionnaire, a Questionnaire for Sensitive
Positions, a personnel qualifications statement, a personnel security interview, written or oral statements made in response to official inquiry on a
matter that is relevant to a determination regarding eligibility for DOE access authorization, or proceedings conducted pursuant to the DOE
administrative review process under the provisions of Title 10, Code of Federal Regulations, Part 710.

g)

Failed to protect classified matter, or safeguard special nuclear material; or violated or disregarded security or safeguards regulations to a degree
which would be inconsistent with the national security; or disclosed classified information to a person unauthorized to receive such information.

h)

An illness or mental condition of a nature which, in the opinion of a board-certified psychiatrist, other licensed physician or a licensed clinical
psychologist, causes, or may cause, a significant defect in judgment or reliability.

i)

Refused to testify before a Congressional Committee, Federal or state court, or Federal administrative body, regarding charges relevant to eligibility
for DOE, or another Federal agency’s access authorization.

j)

Been, or is, a user of alcohol habitually to excess, or has been diagnosed by a board-certified psychiatrist, other licensed physician or a licensed
clinical psychologist as alcohol dependent or as suffering from alcohol abuse.

k)

Trafficked in, sold, transferred, possessed, used, or experimented with a drug or other substance listed in the Schedule of Controlled Substances
established pursuant to Section 202 of the Controlled Substances Act of 1970 (such as marijuana, cocaine, amphetamines, barbiturates, narcotics,
etc.) except as prescribed or administered by a physician licensed to dispense drugs in the practice of medicine or as otherwise authorized by law.

l)

Engaged in any unusual conduct or is subject to any circumstances which tend to show that the individual is not honest, reliable, or trustworthy; or
which furnishes reason to believe that the individual may be subject to pressure, coercion, exploitation, or duress which may cause the individual to
act contrary to the best interests of the national security. Such conduct or circumstances include, but are not limited to, criminal behavior, a pattern
of financial irresponsibility, or violation of any commitment or promise upon which DOE previously relied to favorably resolve an issue of access
authorization eligibility.

I herewith certify that I have read and understand the above.

(Signature)

(Date)

BOTH SIDES OF THIS FORM MUST BE READ AND SIGNED
18 U.S.C. SECTION 1001; ACT OF JUNE 25, 1948; 62 STAT. 749; MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT
OR PRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTERS WITHIN ITS JURISDICTION.