AD-1197 Request for USDA Identification (ID) Badge

OMB Control No.: 0505-0022
OMB Expiration Date: mm/dd/yyyy

U.S. DEPARTMENT OF AGRICULTURE
REQUEST FOR USDA SITE BADGE
A. Applicant & Source Document Information (To be completed by USDA Human Resources)
Applicant Information
First Name
Middle Name
Last Name
Phone Number

SSN

Position

Birth Date (mm/dd/yyyy)

Company/Agency

Email Address

Applicant Work Address

Street Address

City

State

First Name

Identity Source Document 1 (attach copy)
Middle Name
Last Name

Document No.

Document Title

First Name

Identity Source Document 2 (attach copy)
Middle Name
Last Name

Document No.

Document Title

Issuer

Issuer

Zip Code

Exp. Date (mm/dd/yyyy)

Exp. Date (mm/dd/yyyy)

B. USDA Site Badge Sponsorship (To be completed by USDA Agency/Staff Office Sponsor)
Request Type
Site Badge Type
Reason for Replacement (enter N/A if request is for a new
badge)
New
Replacement (provide reason)
Exp. Date Requested (mm/dd/yyyy)

Access Required

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OMB Control No.: 0505-0022
OMB Expiration Date: mm/dd/yyyy
First Name

Sponsor Information
Last Name

Agency/Staff Office

Work Phone

Work Email Address

I agree to sponsor the above application for a USDA Site Badge and certify that the information is accurate to the
best of my knowledge.
Printed Name of Sponsor
Signature of Sponsor

Date Signed (mm/dd/yyyy)

C. Issuance Approval (To be completed by USDA Personnel Security Adjudicator only after Sections A & B are
complete)
FBI National Criminal History Check Results
Date Completed (mm/dd/yyyy)
Successfully Adjudicated?
Yes
No
Comments:

First Name

Personnel Security Adjudicator Information
Last Name
Work Phone

Agency/Staff Office

Work Email Address

I hereby certify that the information regarding the above applicant is accurate to the best of my knowledge. I
hereby
approve
disapprove this application for USDA Site Badge issuance.
Printed Name of Personnel Security Adjudicator
Signature of Personnel Security Adjudicator

Date Signed (mm/dd/yyyy)

D. USDA Site Badge Issuance Details (To be completed by the USDA Issuer, after Sections A, B, and C are
complete)
Badge Information
Name as it appears on site badge
Badge #
Badge Exp. Date (mm/dd/yyyy)

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OMB Control No.: 0505-0022
OMB Expiration Date: mm/dd/yyyy
First Name
Agency/Staff Office

Last Name

Issuer Information

Work Phone

Work Email Address

I hereby acknowledge issuance of a USDA Site Badge to the applicant identified above based on the verification
of the applicant’s identity and verification of the above Personnel Security Adjudicator’s issuance approval.
Printed Name of Issuer
Signature of Issuer

Date Signed (mm/dd/yyyy)

E. Applicant Acknowledgment (To be completed by the Applicant, after Section D is completed)
I, the Applicant, confirm receipt of the USDA Site Badge identified above and that the information is accurate to
the best of my knowledge.
Printed Name of Applicant
Signature of Applicant

Date Signed (mm/dd/yyyy)

Public Burden Statement: A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor
shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of
the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The
approved OMB Control Number for this information collection is 0502-0022. Without this approval, we could not
conduct this information collection. Public reporting for this information collection is estimated to be approximately 1
hours per response, including the time for reviewing instructions, searching existing data sources, gathering, and
maintaining the data needed, and completing and reviewing the information collection. All responses to this information
collection are voluntary to obtain benefits. Send comments regarding this burden estimate or any other aspect of this
information collection, including suggestions for reducing this burden to the USDA at: 1400 Independence Avenue SW,
Room 1434, Washington, DC 20250, Attn: Director Office of Safety, Security, and Protection – Facility Protection
Division.
Privacy Notice:
Authority: Homeland Security Presidential Directive–12 (HSPD–12), Departmental Physical Security Program, DR 1650–
001, December 9, 2021, and Authority to Operate (ATO), 06/07/2022.
Purpose: The information collected on Form 0505-0022 will be input into Enterprise Physical Access Control System
(ePACS) which provides a centralized infrastructure for the use of the USDA Site Badge for access to federally controlled
facilities as mandated by HSPD–12. The ePACS provides a means for USDA Agencies to deploy electronic access control
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OMB Control No.: 0505-0022
OMB Expiration Date: mm/dd/yyyy
to its facilities; supports the mitigation of identified threats and vulnerabilities; and ensures that unauthorized
individuals do not have access to critical USDA assets.
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974,
records contained in this system may be disclosed outside USDA as a routine use pursuant to 5 U.S.C. 552a(b)(3), to the
extent that such uses are compatible with the purposes for which the information was collected. Such permitted routine
uses include those listed in the System of Records Notice, USDA/OSSP–1, the Enterprise Physical Access Control System
located at Federal Register 36272 Vol. 88, No. 106 dated, June 2, 2023.
Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested
information may delay or prevent the completion of your security threat assessment, which may prevent your access to
secured areas or other area or purpose for which personnel identification are issued.

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