Form PC-1336S Supplemental Intelligence Background Questions

OMB No. 0420-xxxx

Expiration Date: xx/xx/20xx

PC-1336: Supplemental Intelligence Background Questions

Your application (or your relative’s application) discloses a possible connection between your background and the intelligence community. Any semblance of a connection between the intelligence community at the federal, state, or local level and Peace Corps employees or Volunteers could seriously compromise the ability of the Peace Corps to develop and maintain trust and confidence in our host countries.

The purpose of this form is to determine whether your intelligence connection would compromise the Peace Corps’ total separation from intelligence activities, both in reality and in appearance. See Peace Corps Manual Section (MS) 611 Eligibility for Peace Corps Employment or Volunteer Service of Applicants with Intelligence Backgrounds and its implementing procedures. Regarding eligibility for Peace Corps Volunteer service, see also 22 CFR 305.6.

We require this form of any applicant who has:

1. engaged in intelligence activities or been employed by an intelligence agency, OR

2. an immediate family member (i.e., parent, child, sibling or spouse) who is or has been so engaged or employed.

If you have ever worked for the Central Intelligence Agency (CIA), you are not eligible for Volunteer service or employment at the Peace Corps, and you should not fill out this form.

If you have any other type of possible intelligence connection, your application will not be considered until you submit this form.

The person who works or has worked in intelligence should complete this form. If the applicant’s immediate family member works or has worked in intelligence, the immediate family member should complete the form, not the applicant. Usually relying on memory is sufficient to answer most of the questions.

If you have an immediate family member who works or has worked for the CIA, you should not give them this form to complete. Please contact your relative in person, not by phone, email, social networking, or any other means that is not in person, and ask him or her to contact the Office of General Counsel at the CIA.

If your intelligence connection involves the National Security Agency (NSA), you (or, if the connection is with a family member, that person) must contact NSA’s Prepublication Review Office at 443-634-4095 before submitting this form to the Peace Corps.

After we review this form, we may find you fully eligible for service, we may bar you from service for a specific period of time, or we may limit your service to certain parts of the world. If serious doubts exist about an applicant's intelligence connection, the issue will be resolved in favor of exclusion from service.

If you disagree with the eligibility decision, you may appeal to the Director of the Peace Corps. You may email your appeal to [email protected].

If you have any questions about this form, please contact the Peace Corps Office of the General Counsel at [email protected].

Definitions:

For the purposes of this form:

• Intelligence activity includes any activities or specialized training involving or related to the clandestine collection of information, or the analysis or dissemination of such information, intended for use by the United States government in formulating or implementing political or military policy in regard to other countries. The term also includes any involvement in covert actions designed to influence events in foreign countries.

• Intelligence agency means an agency, or division of an agency, a substantial part of whose mission includes intelligence activities.

• Employment, employee, or employed refers to the existence of a relationship of employer and employee, whether full-time or part-time, permanent or temporary, without regard to the length of time the relationship existed or is proposed to exist, and includes, for purposes of the policy set forth at MS 611, individuals performing duties as volunteers, fellows, interns, consultants, contractors, and personal service contractors.

• Agency means any state, county, municipal, federal agency, or instrumentality of the United States Government.

Disclosure of this information may be prohibited by law. If so, it may be necessary for you to consult the Office of the General Counsel of the agency involved before responding. The agency involved should advise whether or not the facts requested may be disclosed. The agency may elect to discuss these issues with the Office of the General Counsel at the Peace Corps to expedite a decision.

If disclosure is prohibited, please contact the Office of the General Counsel at the Peace Corps to discuss your particular case to the extent you can do so. The Peace Corps will consult with the agency involved in order to determine how to proceed.

The Peace Corps policy at MS 611, the language of which will govern the final decision, is linked to above. If you have any questions, please email them to [email protected]. If you are authorized to provide the information, or if the work was of a nature that does not require authorization, please proceed with completing and submitting this form to the specified recipient.

A decision regarding your eligibility, based on the information you provide, will be made as soon as possible.

Privacy Act Statement

The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974, 5 U.S.C. 552a (The Privacy Act) to advise you of the following information regarding this form. The Peace Corps follows the requirements of the Privacy Act which protects personal identifiable information that the agency maintains and uses in its systems of records.

Authority: The Peace Corps Act, 22 U.S. Code § 2501 – Congressional declaration of purpose; and MS 611 Eligibility for Peace Corps Employment or Volunteer Service of Applicants with Intelligence Backgrounds.

Purpose: The purpose of this form is to determine your eligibility for hire for a position at the Peace Corps.

Routine Uses: Use of the information collected based on this form is restricted to the purposes cited in this privacy statement or unless the disclosure is otherwise permitted under the provisions of the Privacy Act of 1974, and the agency’s privacy policy. The information you provide may be used for the routine uses described in the Privacy Act, and the Peace Corps’ published General System of Records Notices PC-8 Legal Files – Staff, Volunteers and Applicants for Employment.

Disclosure: The information you provide is voluntary. However, failure to provide complete information and to submit this form may slow down the hiring process, and will eventually disqualify you from being hired for a Peace Corps position. The agency is committed to ensuring that any personal information it receives is safeguarded against unauthorized disclosure.

Paperwork Reduction Act Notice (Burden Statement)

Public reporting burden for this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions and completing the information. You do not have to supply this information unless this collection displays a currently valid OMB control number. Send comments on the accuracy of this burden estimate and/or recommendations for reducing it to the Privacy Officer, Peace Corps, 1275 First Street, NE, Washington, DC 20526, or [email protected].

Please be as specific as you can when you respond to the following questions. Unless otherwise indicated, please answer all questions.

1. Are you the applicant? (If the answer is yes, skip to question 3.)

2. Are you the applicant’s relative? If so, how are you related to the applicant? Do you currently live with the applicant and, if not, when was the last time you lived with the applicant? Is the relative deceased?

3. Are you, or were you, previously employed by or contracted with an intelligence agency? (If the answer is no, skip to question 9.)

4. Which intelligence agency are, or were, you employed by, or contracted with?

5. When were you first employed by, or contracted with, an intelligence agency?

6. When were you last employed by, or contracted with, an intelligence agency?

7. Where are, or were, you employed by, or contracted with, an intelligence agency?

8. Was your employment by, or contract with, an intelligence agency known to the public?

9. Do you engage in, or have you previously engaged in, intelligence activities? (If the answer is no, skip to question 17.)

10. When did you begin performing intelligence activities?

11. When did you last perform intelligence activities?

12. Where do you, or did you, perform intelligence activities?

13. Did the activity involve contact with foreign nationals?

14. What intelligence-related training did you receive, if any?

15. What duties did you perform?

16. Were your intelligence activities known to the public?

17. Please include any additional information you think may be helpful for the Peace Corps to be aware of in reviewing your, or the applicant’s, application.

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