Form 121-3-1-3A Facility Access Request

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
FACILITY ACCESS REQUEST

OMB Control Number: 1660-NW75
Expiration: MM DD, YYYY

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average .17 hours per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This
collection of information is required to obtain or retain benefits. You are not required to submit to this collection of information unless it displays
a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:
Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency (FEMA), 500 C Street
SW, Washington, DC 20472, and Paperwork Reduction Project (1660-NW75). NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why DHS is requesting the information on this form.
AUTHORITY: FEMA is authorized to collect the information requested on this form pursuant to 40 U.S.C § 13159 to protect the buildings,
grounds, and property owned, occupied, or secured by the Federal Government, and the persons on the property.
PURPOSE: FEMA is requesting this information to collect and maintain records related to the Department's facility and perimeter access
control, including access to DHS information technology and access to facilities, as well as visitor security and management. FEMA will use
this information to support the Department's efforts related to protecting DHS facilities and operating the visitor management program.
ROUTINE USES: The information requested on this form may be shared externally as a “routine use” to FBI to assist the Department of
Homeland Security in screening FEMA employees requesting access to high security areas and visitors that are not employed by the U.S.
Government. A complete list of the routine uses can be found in the system of records notice associated with this form, “Department of
Homeland Security FEMA. DHS/ALL-024 Facility and Perimeter Access Control and Visitor Management System of Records, DHS/ALL-023
Personnel Security Management System of Records, DHS/ALL-025 Law Enforcement Authority in Support of the Protection of Property
Owned, Occupied, or Secured by the Department of Homeland Security System of Records and DHS/ALL-026 Personal Identity Verification
Management System of Records The Department's full list of system of records notices can be found on the Department's website at http://
www.dhs.gov/system-records-notices-sorns.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Providing this information to is voluntary. However, failure to provide this
information may result in a denial of access to FEMA facilities.

INSTRUCTIONS FOR ACCESS TO FEMA FACILITIES
(FOR MOUNT WEATHER EOC (MWEOC) AREA A, SEE SPECIFIC INSTRUCTIONS BELOW)
1.
2.
3.

4.

To apply for access into FEMA controlled facilities, all applicants must TYPE or PRINT the applicable parts of this form. Fill out, sign
and return to the point of contact. Part I of this form must be completed and signed by the person applying.
The point of contact must sign and forward completed form to the Facility Security Manager.
Applicants requesting access to be programmed onto an existing PIV Card must know their PIN Number.
Authorized personnel may have access to rooms/suite entry door within FEMA space only after coordination/endorsements from the
servicing program office of the space in question and the Office of the Chief Security Officer (OCSO). If you have questions, you can
call the OCSO at (202) 646-3012.
FEMA Employees or Contractors: Complete Part I.Visitors without an existing PIV Card: Complete Parts I and II. Guests
requesting access with an existing PIV Card: Complete Parts I, II, and III.

INSTRUCTIONS FOR ACCESS TO MOUNT WEATHER EMERGENCY OPERATIONS CENTER (MWEOC) AREA A
1.
2.
3.
4.

Pursuant to CFR 44 Part 15, the FEMA Administrator or MWEOC Executive Director must approve all persons and vehicles entering
MWEOC.
Government Employees, Contractors or Vendors: Complete Part I - TYPE or PRINT Part I. Return the signed form to the
approved MWEOC sponsor.
Approved MWEOC Sponsor: Complete Part II and forward the completed form to the MWEOC Access Control Office via fax at
540-542-2608 or by email at [email protected] (Incomplete forms and forms not sent by an approved
MWEOC sponsor will not be processed.)
Applicants requesting access to be programmed onto an existing PIV Card must know their PIN Number. Authorized personnel may
have access to rooms/suite entry door within MWEOC only after coordination/endorsements from the approved MWEOC Sponsor of
the space in question and the MWEOC Access Control Office. If you have questions, you can call the MWEOC Access Control office
at (540) 542-2091.

FEMA FORM 121-3-1-3A (04/20)

Page 1 of 3

NOTE: Signing this form signifies that I understand that this is a Release Of Information(ROI). I understand that any false statement
on any part of my application may be grounds for denying me access into Federal Emergency Management Agency controlled
facilities, and/or grounds for prosecution under Title18 USC 1001.
***Please ensure to use a cover sheet and password protect or use other approved methods for the protection of the applicant's PII
when submitting this form***
PART I - TO BE COMPLETED BY APPLICANT FOR ACCESS TO FEMA FACILITIES/MWEOC AREA A
***Signing this form is a release of Information (ROI)***
FULL NAME OF APPLICANT (Last, First, Middle, and Maiden if applicable)

CURRENTLY HAVE A PIV, PIV-I, or CAC CARD? (Check one)

YES

SPONSOR PROGRAM OFFICE

IF YES, WHAT ISSUING AGENCY?

NO

TELEPHONE NUMBER
DATE OF BIRTH (MM/DD/YYYY) SEX
MALE
FEMALE HOME

CELL
WORK

PLACE OF BIRTH (CITY, STATE, COUNTRY)

DO YOU HOLD A U.S. CITIZENSHIP STATUS? ARE YOU A NATURALIZED CITIZEN?
YES
YES
NO
NO

SOCIAL SECURITY NUMBER

IF NO, PROVIDE ALIEN REGISTRATION #

EMPLOYMENT STATUS
FEDERAL

CONTRACTOR

IF YES, PROVIDE NATURALIZATION
DATE/ALIEN #
EMPLOYER AGENCY/COMPANY

VENDOR

OTHER

SIGNATURE OF APPLICANT (see ROI/PRIVACY ACT STATEMENT)

DATE

PART II - TO BE COMPLETED BY THE GOVERNMENT SPONSOR
***Signing this form is a release of Information (ROI)***
GOVERNMENT SPONSOR(Last, First, Middle)

SITE(S) TO BE ACCESSED BY
APPLICANT (BUILDING)

SPONSOR PROGRAM OFFICE

FREQUENCY OF ACCESS REQUIRED (Check one) LENGTH OF ACCESS REQUIREMENT
Start Date
Daily

FLOOR/ROOM/SUITE ENTRY DOOR TO
BE ACCESSED BY APPLICANT

SIGNATURE OF SPONSOR

FEMA FORM 121-3-1-3A (04/20)

Weekly

Monthly

Other

End Date

REASON FOR ACCESS (MEETING, CONTRACT, ETC.)

SPONSOR'S EMAIL

POC PHONE NO.

DATE

Page 2 of 3

PART III - TO BE COMPLETED BY AGENCY'S SECURITY OFFICER
MUST be completed for any visitor/guests requiring access to classified information.
***Signing this form is a release of Information (ROI)***
ORGANIZATION SECURITY OFFICER NAME AND AGENCY

SIGNATURE

DATE

CONTRACT NO. (IF APPLICABLE) CONTRACT EXPIRATION DATE (IF CURRENT INVESTIGATION ON FILE? INVESTIGATION TYPE
APPLICABLE)
YES
NO
DATE OF INVESTIGATION

INVESTIGATING AGENCY

CLEARANCE LEVEL (if applicable)

DATE GRANTED

SPECIAL ACCESS (IF APPLICABLE) SI - TK - G
DATE BRIEFED
HCS DATE BRIEFED

FEMA FORM 121-3-1-3A (04/20)

Page 3 of 3