3245-0320 HUBZone Level 2 Program Exam (Site Visit) Report Form 11-29-2022

HUBZone Site Visit Report Form
Revised for Virtual Visits

A. Firm Profile:
Complete this section prior to conducting the site visit. You will need to communicate with a
representative of the firm to answer question 8 and 9 (if applicable) and ensure you are visiting the
location that was the principal office at the time of the firm’s certification anniversary date.

1. SBA User ID:
2. DUNS:
3. Firm Name:
4. Firm certification anniversary date:
5. Number of locations:
6. Location address as it appears in DSBS:
7. Average number of employees of the firm as it appears in
DSBS:
8. According to the representative of the firm, was the address in block 6 the firm’s
principal office at the time of the firm’s certification anniversary date?
If yes, skip to question 10.
In no, continue to question 9.
9. According to the representative of the firm, why was the address in block 6 not the principal office
at the time of the firm’s certification anniversary date?
a. The principal office was a different location of the firm.
If yes, ask the representative of the firm to send the DSBS profile for the location that
was the principal office. Enter the location address as it appears in DSBS below.

b. The firm has relocated and no longer owns or leases the location that was the
principal office at the time of the certification anniversary date.
If yes, enter the address that was the principal office below. Skip the remainder of

the questions and sign and submit this form. The HUBZone program office will
request additional information from the firm.

c. Other reason.
Explain the circumstances in the text box below. Skip the remainder of the questions
and sign and submit this form. The HUBZone program office will request additional
information from the firm.

10. Is the address in block 6 or block 9a in your District Office’s jurisdiction?
If yes, proceed to question 11.
If no, skip the remainder of the questions and sign and submit this form. The
HUBZone program office will reassign the site visit to the appropriate District Office.
11. Is the address in block 6 or block 9a in a HUBZone?
If yes, visit the location.
If no, skip the remainder of the questions and sign and submit this form. The
HUBZone program office will request additional information from the firm.

B. Site Visit Information
Complete this section using information collected during the site visit.
1. Date of Site Visit:
2. Name of SBA employee conducting the site visit:
3. How was the external presence verified?
If in person, take photo(s) and submit with this report form.
4. How was the internal presence verified?
5. Name and title of representative(s) of the firm you spoke with.
6. Does it appear the firm is currently operating out of this location? Note any issues or
irregularities below.

7. Describe any company signage you observed.
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8. Does it appear other firms are working out of the same office space? Note any issues or
irregularities below.

9. Is the facility appropriate for firm’s type of business (not a personal residence unless a
home-based business)? Add comments, as necessary, below.

10. Describe the office equipment/ furniture present, including phones, computers, and desks. Note
any issues or irregularities.

11. How many employees does the representative of the firm report worked at this
location during the four-week period immediately prior to the most-recent certification
anniversary date or, if applicable, would have been working at the location if not for
COVID-19 related telework? Add comments, as necessary, below.

12. Is it plausible that the number of employees reported in block 11 could have been
working at this location or, if applicable, could have been working at this location if not for
COVID-19-related telework? Add comments, as necessary, below.

13. Is there any indication this may not be the principal office? Add comments, as
necessary, below.

Space for additional notes, if needed.

Signature
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Instructions:
A. Firm Profile:
BLOCK 1: Enter the information as it appears on the Site Visit List (Column A)
BLOCK 2: Enter the information as it appears on the Site Visit List (Column B)
BLOCK 3: Enter the information as it appears on the Site Visit List (Column D)
BLOCK 4: Enter the information as it appears on the Site Visit List (Column L)
BLOCK 5: Enter the information as it appears on the Site Visit List (Column R)
BLOCK 6: Use the DUNS number to search for the firm’s profile in DSBS and enter the address as
it appears there.
BLOCK 7: Enter the information as it appears in DSBS. Note, this is the average number of
employees for the firm, not a specific location of the firm.
BLOCK 8: Select the appropriate response.
BLOCK 9: Select the appropriate response, if applicable.
BLOCK 10: Select the appropriate response.
BLOCK 11: Enter the address into the HUBZone Map (sba.gov) and indicate whether it is in a
HUBZone. The principal office of a firm must be located in a HUBZone.
B. Site Visit Information:
BLOCK 1: Enter the date(s) the site visit was conducted.
BLOCK 2: Enter response.
BLOCK 3: Select how the internal presence was verified. Note: For virtual site visits, the firm
should show the building front, street address, neighboring buildings, office directory or signage
to demonstrate the firm’s presence at the location.
BLOCK 4: Select how the external presence was verified. Note: For virtual site visits using a live
video streaming application, request to see evidence of organizational presence as outlined in
items 6-12 of Section B of this form.
BLOCK 5: Enter response.
BLOCK 6: Enter response and comments, as necessary.
BLOCK 7: Enter response.
BLOCK 8: Enter response and comments, as necessary.
BLOCK 9: Enter response and comments, as necessary.
BLOCK 10: Enter response.
BLOCK 11: Enter response and comments, as necessary.
Block 12: Enter response and comments, as necessary.
Block 13 Enter response and comments, as necessary.
SIGNATURE BLOCK: Make sure the form is signed by the person who performed the site visit. If you
are unable to electronically sign, print, sign, and scan the form.
Submission:
Email the electronically signed form and supporting documentation (as applicable) to
[email protected] with the subject line “SITE VISIT /SBA User ID PXXXXXXX .

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