Investigative Interview Survey

Revised October 2019
OMB Control Number: 0705-0004
Expiration Date: 08/31/2022

January 12, 2022

«I_First» «I_Last»
«ADDRESS1»
«ADDRESS2»
«CITY», «STATE» «ZIP»

Dear «I_First» «I_Last»:
You were contacted by «A_First» «A_Last», an Investigator with the Defense
Counterintelligence and Security Agency, as part of a Federal background investigation for
«S_First» «S_Last».
We are proud of our reputation as a provider of background investigations and we strive to
ensure that our investigations are conducted on the highest professional level. We have found
that comments and suggestions from people who have been interviewed are extremely helpful in
achieving this goal.
Your completion of the brief questionnaire on the back of this letter is voluntary and would be
greatly appreciated. When responding, do not include personally identifiable information (PII)
relevant to the subject of investigation. If your name and address are incorrectly shown on this
letter, please correct your name and address where they are shown above.
We are enclosing a pre-addressed, postage-free envelope for you to use to return the
questionnaire. Thank you for your assistance with the investigation and for your time and effort
completing the questionnaire.
Sincerely,

Enclosure

Jeffrey C. Flora
Deputy Assistant Director, Quality Oversight
Defense Counterintelligence and Security Agency

AUTHORITY: Section 925 of Public Law 115-91; Executive Order 13467, as amended by Executive Order 13869; DoD Directive 5105.42.
PRINCIPAL PURPOSE: The primary purpose of the information you furnish will be to assess the quality, conduct, and professionalism of the investigator identified
above during the course of the investigation. The agency uses this information to appraise, instruct, and improve the performance of federal employee and contractor
investigators, and to inform the training provided to investigators.
ROUTINE USES: The information collected may be disclosed to DCSA personnel and shared externally with other authorized government agency personnel as a
routine use when necessary and relevant to personnel investigations, criminal law enforcement or counterintelligence activities, employment actions, and legal
proceedings; and, for other purposes permitted under subsection (b) of the Privacy Act of 1974, as amended (5 USC §552a). Information obtaine d will also be released
to the investigator about whom the information is collected upon their request unless otherwise exempt.
DISCLOSURE: Disclosure is voluntary. There are no adverse effects if you do not complete this form.
PUBLIC BURDEN INFORMATION: The public reporting burden for this collection of information, OMB Control Number 0705-0004, is estimated to average six
minutes per response, including the time for reading the letter and for reviewing and completing and reviewing the collection of information. Send comments regarding
the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.

N *«ID»* «Org_ID»

1
Were you interviewed in person or over the phone?

□ IN PERSON

(Proceed to Question
2a)

□ BY PHONE

(Proceed to Question
2b)

2a

For interviews conducted in person:

Was the Investigator dressed professionally and well groomed?

□ YES

□ NO

Did the Investigator show you credentials and introduce himself/herself
as a Special Agent or Contract Investigator with the Defense Counterintelligence and
Security Agency?

□ YES

□ NO

□ YES

□ NO

□ YES

□ NO

□ YES

□ NO

□ YES

□ NO

3
Was the Investigator polite and professional?

□ YES

□ NO

4
Did the Investigator explain that the interview was for employment or security clearance purposes?

□ YES

□ NO

5
Were questions presented in a clear manner so that they could be understood easily?

□ YES

□ NO

- Do not provide PII, to include names, for the following responses:

Were you interviewed alone (no third party present)?
If "NO", please explain:_________________________________________________
Were you interviewed in a private setting or private, enclosed space?
If "NO", please explain:_________________________________________________
2b

For interviews conducted by phone:

Did the Investigator introduce himself/herself as a Special Agent or Contract Investigator
with the Defense Counterintelligence and Security Agency?
Were you offered to be interviewed in person?
Please explain why the interview was conducted by telephone: _____________________

6
The information you provided about the person being investigated (check one )…

□ ...was favorable.

□...included issues
or concerns.
If you told the Investigator about concerns regarding the individual being investigated, note the type or category of concern in the space
provided. Do not provide detailed information about the concern or include PII relevant to the subject of investigation in your response.
Examples of types or categories of concern include: criminal conduct, illegal drug use, alcohol abuse, violent behavior, foreign travel.
CONCERNS:

7
Please provide additional details to your responses above and any comments/concerns you have about the investigator and/or the
interview. Also indicate if you require additional contact from a DCSA representative. (Note: When responding, do not include PII or personal
details about the subject of the investigation.)

8

Signature:________________________________________________ Date:_____________________________
Please provide your contact information:

Daytime telephone number: (

) ________ - ____________

Email address:__________________________________________