DOE F 5631.20 Request for Visit or Access Approval

DOE F 5631.20
(10/2021)

OMB Control No.
1910-1800
Expires 10/31/2021

U.S. DEPARTMENT OF ENERGY
REQUEST FOR VISIT OR ACCESS APPROVAL
(Not to be used for temporary or permanent personnel assignments)
PART “A”
Date:
Prepared by:
Symbol:
Telephone No:

To:
From:

It is requested that the following person(s) be granted visit/access approval:

CHECK
U.S
ALIEN
CITIZEN

LAST NAME, FIRST, MIDDLE INITIAL
AND SOCIAL SECURITY NUMBER

NAME OF FACILITY(IES) TO BE VISITED:

DATE OF
BIRTH

ORGANIZATION

FOR THE INCLUSIVE DATES

FOR BADGE OFFICE TO COMPLETE
TYPE OF
CLEARANCE
DATE OF
CLEARANCE
NO.
CLEARANCE

DOE Security Official Verifying DOE Clearance

FOR THE PURPOSE OF:
TO CONFER WITH THE FOLLOWING PERSON(S):
SPECIFIC INFORMATION TO WHICH ACCESS IS REQUESTED:

Access requested to:
Restricted Data
Other classified info

Prior arrangements have/have not been made as follows:

Yes
Yes

No
No

CERTIFICATION FOR PERSONNEL HAVING DOD CLEARANCE

This certifies that the person(s) named above needs this access in the performance of duty and that permitting the above access will not endanger the
common defense and security.
Authorized access to Critical Nuclear Weapon
Design Information (CNWDI) in Accordance
with DOE Directive 5210.2
Yes
No
_________________________________________
Name and Title, Requesting DOD Official
_________________________________________
Title, Authorizing DOD Official
(See DOD Directive 5210.2 and 5210.8)

__________________________________________________________
Signature
(See AR 380-150; OPNAV 5510.3F; AFR 205-1)

CERTIFICATION FOR PERSONNEL HAVING DOE CLEARANCE
This certified that the person(s) named above needs this access in the performance of duty.

_________________________________________
Title

__________________________________________________________
Requesting DOE or Other Government Agencies
PART “B”

Approval is granted with limitations indicated below:

___________________________________________________________
Manager of Operations/or Headquarters Division Director
SEE REVERSE OF PART 5 FOR PRIVACY ACT INFORMATION STATEMENT

PRIVACY ACT INFORMATION STATEMENT
Collection of the information requested is authorized by Section 145 of the Atomic
Energy Act of 1954, as amended (PL 83-703, 42 USC 2165). The collection of this
information is mandatory to protect national security and other critical assets
entrusted to the Department. The information you furnish will be used by DOE and
DOE contractors to control access to classified information and areas.
The social security number is not required for these purposes, but you may voluntarily
furnish it to assist us in correct identification.

BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 2.5
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. The collection of this information is mandatory to
protect national security and other critical assets entrusted to the Department. Send
comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to Office of Environment,
Health, Safety and Security, U.S. Department of Energy, 1000 Independence Avenue,
S.W., Washington, D.C. 20585; and to the Office of Management and Budget (OMB),
Paperwork Reduction Project (1910-1800), Washington, DC 20503.