Form INV 43 INV 43 Investigative Request for Education Record Data

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INV FORM 43 (Rev. 10/21)
DEFENSE COUNTERINTELLIGENCE
AND SECURITY AGENCY (EO 13467)
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INVESTIGATIVE REQUEST FOR
EDUCATIONAL RECORD DATA
U.S. GOVERNMENT USE ONLY

DEFENSE COUNTERINTELLIGENCE AND SECURITY AGENCY
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
BOYERS, PA 16018-0618

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INSTRUCTIONS: Your contact information was provided by the person identified below to assist in completing a background
investigation to help us determine this person’s eligibility for employment or security clearance. To help us make this
determination, we ask that you complete all items on the back of this form and return the form in the enclosed envelope.
PRIVACY ACT STATEMENT: The information you provide, including your identity, will be furnished to the agency requesting the investigation, other agencies as warranted,
and to the person investigated upon his or her specific request. AUTHORITY: Section 925 of Public Law 115-91; 5 USC 301; Executive Order 13467, as amended by Executive
Order 13869; and, 5 CFR 736. PRINCIPAL PURPOSE: To obtain background information and personal records for investigating and determining an individual’s initial or
continued: eligibility for access to classified national security information or assignment to positions with sensitive duties, suitability for enlistment or appointment into military
service, suitability for federal employment, fitness for assignment to work under contract for or on behalf of the government, or eligibility for physical or logical access to U.S.
Government systems or facilities. 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 vetting investigations, determinations, and adjudications; and, for other purposes permitted under
subsection (b) of the Privacy Act of 1974, as amended (5 USC §552a). Information obtained will also be released to the person being investigated upon their request unless
otherwise exempt. A complete list of the routine uses can be found in the system of records notice for the Department of Defense Personnel Vetting Records System, “DUSDI
02-DoD” at: https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records. DISCLOSURE: Disclosure is voluntary. However,
failure to provide DCSA access to the requested information may result in our agency’s inability to conduct a thorough investigation and may prevent the government from making
a determination or adjudication regarding the qualifications, suitability, eligibility or fitness of the person being investigated.
CERTIFICATION: The person we are investigating has given written consent for this investigative inquiry. We keep that consent on file. If a copy is required in order to complete
this form, please indicate this requirement in writing on the reverse.

Completion and return of this original form as soon as possible will help this person and the agency perform their duties
in a more timely and efficient manner.
CASE NUMBER:

CASE TYPE:

ITEM NUMBER:

FULL NAME (LAST, FIRST, MIDDLE)
OTHER NAMES USED

DATE OF BIRTH

SOCIAL SECURITY NUMBER

POSITION REQUIRING INVESTIGATION

PLACE OF BIRTH
THIS PERSON CLAIMED ATTENDANCE AS FOLLOWS
FROM (MO/YR)
SCHOOL NAME AND ADDRESS
TO (MO/YR)
DEGREE AND DATE (MO/YR)

LAST CLAIMED RESIDENCE DURING PERIOD OF ATTENDANCE

PUBLIC BURDEN STATEMENT: The public reporting burden for this collection of information, OMB 0705-0003, is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, 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.

U.S. GOVERNMENT PUBLISHING OFFICE

221434-7

EXPIRATION DATE: 10/31/24

FORM APPROVED: OMB:0705-0003
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MARKING
INSTRUCTIONS
CORRECT MARK:

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• USE A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY.
• DO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER.
• DO NOT MAKE ANY STRAY MARKS ON THIS SHEET.

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INCORRECT MARKS:

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PLEASE COMPLETE THE ITEMS SHOWN BELOW
1

TO THE BEST OF YOUR KNOWLEDGE, IS THE INFORMATION ON THE FRONT OF THIS FORM THE SAME AS SHOWN IN YOUR
RECORDS?

a

2

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» YES

b
c

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» NO (List discrepancies in REMARKS section)
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» WE HAVE NO RECORD ON THIS PERSON

d

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» RECORD AT ANOTHER LOCATION

(Enter address and ZIP Code in REMARKS)

DO YOUR RECORDS CONTAIN ANY ADVERSE INFORMATION RELEVANT TO THIS PERSON?

a

\
» NO

b

\
» YES (Explain in REMARKS section)

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» IF ADDITIONAL REMARKS ARE PROVIDED BELOW, YOU MUST FILL IN THIS MARK
REMARKS

PRINT NAME:

DATE

SIGNATURE:

YOUR TITLE/ORGANIZATION:

DAYTIME TELEPHONE NUMBER
(INCLUDE AREA CODE)

(

)

FOR DCSA USE ONLY
ISSUES/CHARACTERIZATION

RESULTS
AC ACCEPTABLE
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AA
\ ACCEPTABLE/ATTACHED
PA CONFIDENTIAL/ACCEPTABLE
\
NI NO PERTINENT INFORMATION
\
NR
\ NO RECORD
NL NOT LOCATED
\
UC
\ UNABLE TO CONTACT
RF REFERRED
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RR
\ RECORD

IS ISSUES
\
PI CONFIDENTIAL/ISSUES
\
RI
\ RECORD INCONCLUSIVE
FR FEE REQUIRED
\
RL RELEASE REQUIRED
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SK
\ SUBJECT UNKNOWN
NZ NOT AVAILABLE
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DN
\ DISCREPANT

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