Researcher SAC For Researcher SAC Form

OMB No. 1220-0180

Bureau of Labor Statistics

Special Agreement Check (SAC) Information

Instructions

All visitors to the Bureau of Labor Statistics (BLS) national headquarters building require a minimal background check. The information collected on this form is used to check government repositories for prior vetting information and/or to conduct a Special Agreement Check (SAC). All your answers must be truthful and complete. A false statement on any part of this form may be grounds for denying access to BLS facilities and confidential BLS data.

After the vetting/SAC is completed, you will be contacted regarding additional steps necessary to access confidential BLS data. Once all requirements have been fulfilled, the BLS will issue you a temporary building access card. You will not be a federal employee or contractor upon completion of the SAC.

The information you provide on this form will be entered into the federal credentialing system, USAccess. You will receive an email with instructions to schedule an appointment to have your fingerprints recorded at a federal government facility if you do not already have applicable security vetting. If you are not currently in the United States, please do not submit this form until you return, since you will not be able to have your fingerprints recorded outside the country.

The form should be submitted as a password-protected email attachment or faxed, since it will contain your social security number and other personally identifiable information. It should be submitted only to your primary BLS contact.

Privacy Act Statement

The information you provide will be used by staff at the Department of Labor to check government repositories for prior vetting and/or to conduct a Special Agreement Check (SAC) to determine your fitness to access restricted BLS data. It may be disclosed to other authorized federal officials as part of the SAC process.

In accordance with the Privacy Act of 1974 as amended (5 U.S.C. 552a), details about routine uses can be found in the system of records notice, OPM/GOVT-1, General Personnel Records.  Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Providing the information on this form is voluntary. However, the BLS will not be able to grant access to restricted BLS data without this information.  The BLS is authorized to request the information on this form under Title 5, United States Code, Section 301. 

Burden Statement

We estimate that it will take 10 minutes to complete this form. The responses to this collection of information are voluntary. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Email comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Labor, Bureau of Labor Statistics, Division of Management Systems, Attention: BLS Clearance Coordinator, [email protected].

General Information
If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, enter "No Middle Name". If you are a "Jr.," "Sr.," etc. enter that suffix after your last name.
1. First Name
2. Middle Name
3. Last Name
4. Email Address
5. Phone (include area code)

Background Information
6. Date of Birth (MM/DD/YYYY)
7. Social Security Number
8. Place of Birth (City & State; Non-US Born, City/Provence & Country)
9a. Are you a U.S. Citizen?	Yes ☐ No ☐ (If "Yes", proceed to question 10)
9b. Have you been a Resident of the United States for 3 or more years?	Yes ☐ No ☐
10. Do you have current Census Special Sworn Status (SSS)?	Yes ☐ No ☐
11. Have you had any prior FED/FED Contract Employment within the last 24 months?	Yes ☐ No ☐ (If "Yes", proceed to questions 12-15)

Prior Federal Employment
Only respond if you have been employed by the Federal Government within the last 24 months.
12. Prior Employment Type	Federal ☐ Contractor ☐ Other (specify) ☐
13. Agency
14. Start Date (MM/DD/YYYY) (If exact start and end dates are unknown, please use the first day of the month)
15. End Date (MM/DD/YYYY) (If applicable, state “Employment Current”.)

Signature

_________________________________ _____________________

Applicant Signature Date (MM / DD / YYYY)