Form 11000-16 PIV-O Credential and Shield Request

DEPARTMENT OF HOMELAND SECURITY

Personal Identity Verification Official (PIV-O) Credential and Shield Request

OMB No. 1601-NEW

PRIVACY ACT STATEMENT
AUTHORITY: Homeland Security Presidential Directive 12, "Policy for a Common Identification Standard for Federal Employees and Contractors";
DHS Directive 121-01, "Chief Security Officer"; DHS Directive 121-03, "Common Identification Standard for DHS Employees, Contractors, Visitors, and
Affiliates"; DHS Instruction121-01-002, "Personal Identity Verification Official Credentials and Shields".
PRINCIPAL PURPOSES: Use this form to request a DHS PIV-O credential, and if applicable a shield to accompany the credential, for specific positions
authorized to perform official functions pursuant to law, statute, regulation, or DHS Directive.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as
amended. This includes using this information as authorized by the routine uses published in System of Records Notice "DHS/ALL-026 Personal
Identity Verification Management System" (74 FR 30301).
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested will prevent the applicant
from receiving the requested DHS PIV-O credential and/or shield.
PUBLIC BURDEN STATEMENT
An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it
displays a currently valid Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is
estimated to average 15 minutes per response, including the time for reviewing instructions, gathering any required information, completing and
submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: [email protected].

Section 1: Request Type
Enter the date and select a checkbox for each request type; more than one may apply. For example, a new hire to a position that
requires a DHS PIV-O Credential and DHS Shield may select the Initial Issuance checkboxes for both types.
Request Date
Type
DHS PIV-O

Initial Issuance Reissue - Lost/Stolen Reissue - Position/Credential Update Retire/Separate Honorable Service

DHS Shield

Section 2: Application Information
Enter the applicant's information. An example of an Office/Division within DHS HQ is “I&A”. If the Electronic Data Interchange Personal
Identifier (EDIPI) is unknown, then provide the last four digits of the applicant's Social Security Number (SSN).
Name (Last, First, MI)
E-mail
Entire EDIPI or Last 4 of SSN

Phone Number
Office/Division

DHS Component -Please Select

Section 3: Position Information
Enter the position title as it will appear on the DHS PIV-O credential. The OPM job series and name is applicable only for Federal
employees.
Personnel Type -Please Select

Credential Position Title

OPM Job Series

OPM Job Series Name

Section 4: Justification
The Authorizing Official must provide a justification or legal authority that adequately supports the need for a DHS PIV-O credential
and/or shield. Eligibility criteria is listed in DHS Instruction 121-01-002.

DHS Form 11000-16 (03/2023)

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Section 5: Authorizing Official
The Authorizing Official must provide their name, contact information, and digital signature. The Authorizing Official may vary
according to organizational structure. Examples are provided below.
• Federal Employees: Head of a Division, Office, or Program
• Contractors: Contracting Officer's Representative, Program Manager, or Federal Supervisor
• Foreign Nationals or other Affiliates: Program Manager or Federal Supervisor
By signing this form, the Authorizing Official certifies that the applicant is assigned to a position that meets the eligibility criteria for
receiving a DHS PIV-O credential and/or shield in accordance with DHS Instruction 121-01-002. Submit the completed form to the
applicable DHS Credentialing Facility (DCF).
Name (Last, First, MI)
Office/Division

Position Title

E-mail

Phone Number

Digital Signature

Section 6: Disposition (For DCF Internal Use Only)
Select the appropriate disposition for the request. If the request is disapproved, provide notification and the reason(s) for the
disapproval to the originating office. Provide the name of the DHS PIV-O template type, shield type if applicable, and the adjudicating
official's digital signature.
Disposition

-Please Select

Shield Type

DHS Form 11000-16 (03/2023)

PIV-O Type
Adjudicated By

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