Form TSA Form 2817B TSA Form 2817B SSI ACCESS THREAT ASSESSMENT QUESTIONNAIRE - STANDARD

OMB No. 1652-0042; Exp. 03/31/2025

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
SSI ACCESS THREAT ASSESSMENT QUESTIONNAIRE - STANDARD
INSTRUCTIONS: Applicant: (1) Complete Section I. Providing the optional data may facilitate expedited processing. (2) Review the
application for accuracy and complete Section II. (3) Submit the signed form and all supporting documentation to the program office. (Note: If
Known Traveler Number, prior Federal background investigation, or active security clearance is available, do not complete steps 4 and 5 of
these instructions unless instructed by TSA.) (4) Complete SSI Access Pre-Enrollment. (5) Schedule a date/time for your in-person SSI Access
enrollment at your preferred enrollment center location. Program Office: Review Section I for completion of required information. (2) Verify the
request is signed by the Applicant (Section II). (3) Submit the form to TVS after confirming appointment completed, if required. Use: For use
with members of the public (i.e., non-federal) seeking access to SSI through non-contractual agreement (e.g., conditional disclosures, 15e).

Section I. Contact and Personal Information (All Types)
Full Legal Name (last, first, MI)
Social Security Number (optional)

Aliases and/or Prior Names, if any
Name of Employer (optional)

Work Phone Number (optional)

Email Address (optional)

Place of Birth (City, State, Country)

Country of Citizenship
Alien Registration Number, if applicable

Date of Birth (mm/dd/yyyy)

Gender
Known Traveler Number (KTN)
(optional)

Non-Immigrant Visa Number, if applicable

Passport Country and Number (optional)
If 'Yes', enter date (mm/dd/yyyy)

Prior Federal Background Investigation or Active Security Clearance for access
to classified national security information under E.O. 12958?
Reason for Requesting Access to SSI
(e.g., solicitation number)
Section II. Acknowledgments

1 - Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Applicant Signature:

Date

2 - Should I seek judicial review of TSA’s final decision on my threat assessment, I authorize TSA to release the
foregoing and any other information related to my threat assessment to the court(s) presiding over that review.
Date

Applicant Signature:

PRIVACY ACT STATEMENT: AUTHORITY: 49 USC § 114; HR 5441 Section 525(d); 49 CFR Part 1520. PRINCIPAL PURPOSE(S):
TSA will use this information to conduct a threat assessment on individuals who seek access to Sensitive Security Information (SSI).
ROUTINE USE(S): This information may be shared with law enforcement, intelligence, or other government agencies as necessary to
identify and respond to potential or actual threats to transportation and under the Privacy Act routine uses identified in the TSA system of
records, DHS/TSA-002 Transportation Security Threat Assessment System. DISCLOSURE: Furnishing this information is voluntary;
however, failure to provide the requested information may delay or prevent TSA from completing your security threat assessment, without
which you will not be granted access to SSI.
PAPERWORK REDUCTION ACT STATEMENT: TSA is collecting this information to conduct a threat assessment to determine your
eligibility to gain access to Sensitive Security Information (SSI). This is a voluntary collection of information, but failure to provide the
information may result in an inability to approve your eligibility to gain access to SSI. TSA estimates that the total average burden per
response associated with this collection is approximately 15 minutes. If you have any comments regarding this form, you may write to:
ATTN: TSA PRA Officer, TSA-11, 6595 Springfield Center Drive, Springfield, VA 20598-6011. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB number
for this for is 1652-0042, which expires 03/31/2025.
Previous editions of this form are obsolete
TSA Form 2817B (x/22) rev. [File: 2800.9.2-a]

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