Form 11000-39 Office of Compliance and Security, NPPD Visitor Request

OMB Control Number:[1670-0036]
Expiration Date: 02/28/2021

DEPARTMENT OF HOMELAND SECURITY
Cybersecurity and Infrastructure Security Agency
VISITOR REQUEST FORM

1. Meeting Information
To be completed by the CISA POC. Meeting requests must be submitted from a valid DHS.GOV (FED or CTR) e-mail address

CISA POC:

Phone Number:

Escort:

Phone Number:

Purpose of Visit:
Check if Applicable:

Special Event

Date(s) of Visit:

From:

Location of Visit:

Facility: Glebe Rd

SCIF Tour

Time:

Meeting Classification Level: UNCLASSIFIED

Foreign Visitors

Freight Delivery

Vendor / Service

To:

ITFO / Facilities Project

Time:

Floor & Room:
Access Level:

SI

TK

G

HCS

NATO

2. Visitor Information
To be completed by the CISA POC. All PII must be handled in accordance with DHS Privacy Policy.
If additional space is needed, the 11000-39 Form may be submitted with an attached spreadsheet.

Name

Last Four of SSN
(For Classified Meetings Only)

Agency/Company

3. Click a SUBMIT Button Below
Submit your Visit Request Form to your respective Facility Security Representative
Classified and Unclassified SCIF Visits and Tours
(Submit to the SSO)

Classified and Unclassified General Facility Visits (Non SCIF)
(Submit to the FSO)

Courthouse SSO

Fort Myer SSO

Ballston I

Ballston Qtr (4200)

Courthouse Rd

Glebe; NCCIC; NCC

Jefferson SSO

Crystal Dr

Fort Myer Dr

Glebe Rd

Jefferson Plaza

Wilson Blvd (1550)

Privacy Act Notice | Authority: 5 U.S.C. 301; the Homeland Security Act, codified in Title 6 of the U.S. Code; 44 U.S.C. 3101; and Executive Order (EO)
9397; EO 12968; and Federal Property Regulations, issued July 2002, authorize the collection of this information. | Purpose: This information is being
collected to facilitate DHS facility and perimeter access control, including access to DHS information technology and access to classified facilities, as well
as visitor security and management. | Routine Uses: The information on this form may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the
Privacy Act of 1974, as amended. This includes using information, as necessary and authorized by the routine uses published in DHS/ALL-024 Facility
and Perimeter Access Control Management System of Records. | Disclosure: The disclosure of information on this form is voluntary; however, failure to
provide the information requested may prevent the individual from receiving visit authorization or access to DHS information technology or facilities.
Paperwork Reduction Act: The public reporting burden to complete this information collection is estimated at 10 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and the completing and reviewing the collected
information. The collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number and expiration date. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to Department of Homeland Security, Cybersecurity and Infrastructre
Security Agency, Compliance and Security, 245 Murray Lane, SW, Mail Stop 0640, Washington DC 20598-0640., ATTN: PRA [OMB Control No.
1670-0036].
Form 11000-39 (11/16/2018)

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