Dd Form 1879 – Fill Out and Use This PDF

DOD REQUEST FOR PERSONNEL SECURITY INVESTIGATION

Form Approved

OMB No. 0704-0384

Expires Aug 31, 2002

1. CODE

2. REQUESTER FILE NUMBER

3. DATE OF REQUEST (MM/DD/YYYY)

4. THIS REQUEST IS FOR (X one)

(Optional)

a. SINGLE SCOPE BACKGROUND

INVESTIGATION (SSBI)

5a. FROM

5b. TO

b. PERIODIC REINVESTIGATION (PR)

c. SPECIAL INVESTIGATIVE INQUIRY (SII)

d. EXPANDED NATIONAL AGENCY CHECK

(ENAC)

e. OTHER (Specify in Remarks)

6. DO YOU DESIRE ADVANCE NOTICE OF NAC RESULTS (X one)

YES

NO

7. STATUS (X as applicable)

a. ACCESS TO CLASSIFIED MATERIAL (X one)

8. SUBJECT OF INVESTIGATION

CONFIDENTIAL

SECRET

a.

NAME (LAST, First, Middle Name) (Last name in ALL CAPITALS)

b. SOCIAL SECURITY NUMBER

TOP SECRET

b. CRITICAL NUCLEAR WEAPON POSITION

c. LIMITED ACCESS AUTHORIZATION (LAA)

c.

MAIDEN NAME

d. SENSITIVE COMPARTMENTED

INFORMATION (SCI)

d.

OTHER NAMES USED OR KNOWN BY

e. SIOP-ESI

f.

PRESIDENTIAL SUPPORT

g.

CRITICAL SENSITIVE POSITION/DUTIES

h.

ADP-1

e.

DATE OF BIRTH

f. PLACE OF BIRTH (City, County, State and Country)

g. SEX

i.

NATO ASSIGNMENT

(MM/DD/YYYY)

j.

CRYPTO/COMSEC

k. SPECIAL ACCESS PROGRAM (SAP)

9.

U.S. CITIZENSHIP

a. YES

c. VERIFICATION DOCUMENT REVIEWED

l.

OODEP

VERIFIED (X one)

b. NO

m. OTHER (Explain in Remarks)

10. LOCAL FILES VERIFICATION/PRE-SCREENING INTERVIEW

11. PRIOR INVESTIGATION (X a, b, or c)

DATE REVIEWED

FILES VERIFICATION - UNFAVORABLE

a. YES (Type, Date, By Whom, and File

TYPE (X as applicable)

CONDUCTED

INFORMATION REVEALED (X one)

Number)

c.

(MM/DD/YYYY)

a.

b.

YES

NO

(6) OTHER

b. NO

c. UNKNOWN

12. TITLE OR POSITION OF SUBJECT (If military, list rank and service; if U.S. Government employee, list grade; and if

13. TS BILLET NUMBER

contractor employee, list job title.)

before completing this item.)

FOR DSS USE ONLY

CCN (Case Control Number) (1 - 15)

DSS CLOSING STAMP

(16 - 22)

PB

(72 - 73)

PC

(74 - 75)

Investigations conducted on Army, Navy, and

SV

(76)

CR

(77 - 78)

Air Force military personnel will be returned

COMPLETED

only to the parent service for adjudication

regardless of the source of the original

R

A

I

N

request.

DATE COMPLETED

DD FORM 1879, AUG 1999

PREVIOUS EDITION MAY BE USED.

Page 1 of 4 Pages

FOR OFFICIAL USE ONLY (When filled in)

a. CORRECT

b. PARTIALLY CORRECT (Explain in Remarks)

c. COULD NOT BE VERIFIED (Explain in Remarks)

a. TYPED NAME OF CERTIFIER (Last, First, Middle Name)

b. TITLE OF CERTIFIER

c. SIGNATURE OF CERTIFIER

d. DATE SIGNED BY CERTIFIER

e. TELEPHONE NUMBER

(MM/DD/YYYY)

(Include Area Code)

b. IMMEDIATE SUPERVISOR (Last, First, Middle Name)

c. TITLE

d. SIGNATURE

e. DATE SIGNED (MM/DD/YYYY)

f. TELEPHONE NUMBER

(Include Area Code)

DD FORM 1879, AUG 1999

FOR OFFICIAL USE ONLY (When filled in)

Page 2 of 4 Pages

FOR OFFICIAL USE ONLY (When filled in)

GENERAL INSTRUCTIONS

1. DD Form 1879 is used to request a Single Scope Background

- FD Form 258, "Fingerprint Card." Submit one signed copy.

Investigation (SSBI), Expanded NAC (ENAC) and Additional Investi-

gation, Periodic Reinvestigation (PR), Special Investigative Inquiry

3. The original and two copies of DD Form 1879 will be forwarded

(SII). Its use is restricted to actions involving individuals and it will

to the Defense Security Service (DSS) or the Defense Industrial

not be used to request investigations of incidents, events or

organizations.

Security Clearance Office (DISCO). See Detailed Instructions below.

2. The following documents must accompany each request for

4. The Detailed Instructions for completing Items 1, 4 through 6,

investigation on military, civilian, and contractor personnel.

10 through 17, and 19 are different depending on whether the

- Standard Form 85P, "Questionnaire for Public Trust Positions,"

subject is military personnel, U.S. Government employee, or

is to be used by all Federal agencies as the basis for investigations

contractor personnel.

concerning suitability for positions requiring special public trust

where such positions do not involve access to national security

5. If the Electronic DD Form 1879 is utilized, the requester must

information.

- Standard Form 86, "Questionnaire for National Security

sign the electronically generated DD Form 1879 and retain until the

clearance processing is complete. The signed DD Form 1879 shall

Positions," is to be used by all Federal agencies as the basis for

be released to DSS upon request.

investigations preliminary to granting an individual access to

classified national security information or access to sensitive nuclear

information or materials.

DETAILED INSTRUCTIONS

1. CODE.

7. STATUS.

MILITARY/U.S. GOVERNMENT EMPLOYEES. Enter the Unit

a. ACCESS TO CLASSIFIED MATERIAL. Place an "X" beside the

Identification Code (UIC) or Personnel Accounting System (PAS)

highest level of classified material to which the subject of the

code.

investigation will have access.

CONTRACTOR EMPLOYEES. Enter the Commercial and

b. through m.

Government Entity (CAGE) code for current employment.

MILITARY/U.S. GOVERNMENT EMPLOYEES. Mark the

appropriate block indicating the reason for investigation. If there are

2. REQUESTER FILE NUMBER. To be used by the requester for

any unusual circumstances involving the request, indicate this

internal filing system. This item is optional.

information in Item 18. If block 7.m. is marked, outline in Item 18

the exact reason for the investigation.

3. DATE OF REQUEST. Date you dispatched the request form.

Do not use the same DD Form 1879 to request additional

Enter date in MM/DD/YYYY format. October 30, 2000 would be

investigation on a subject after DSS has completed his/her case. If

10/30/2000.

investigative results are inadequate, provide a new DD Form 1879

and specifically state in Item 18 what investigation you want and

4. THIS REQUEST IS FOR.

substantiate the need for it. Information on the new DD Form 1879

MILITARY/U.S. GOVERNMENT EMPLOYEES. Mark only one

must be accurately transferred from the old DD Form 1879.

block. Requesters requiring additional investigation will mark block

CONTRACTOR EMPLOYEES. If request is for an OODEP, mark

4.e. and indicate "Added Coverage" in Remarks.

block 7.l. and indicate "OODEP" in Item 18.

If request is for Special

CONTRACTOR EMPLOYEES. Mark only one block (a., b., c., or

Access, mark block 7.k. and indicate "Special Access" and the

d.). Do NOT mark block e.

program name (if unclassified) in Item 18.

5. ADDRESSES.

8. SUBJECT OF INVESTIGATION.

a. FROM.

a. NAME. Enter the subject's name in the following order: LAST

MILITARY/U.S. GOVERNMENT EMPLOYEES. Enter name and

name, first name, middle name. The LAST name will appear in all

address (including ZIP Code) of the headquarters, unit, or activity

CAPITAL letters.

submitting the request for investigation.

b. SOCIAL SECURITY NUMBER. Enter subject's Social Security

CONTRACTOR EMPLOYEES. Enter your facility's name and

Number.

address (including ZIP Code).

c. MAIDEN NAME. List maiden name, if applicable. Enter name as

b. TO.

shown below:

MILITARY/U.S. GOVERNMENT EMPLOYEES. Send DD Form

Nee - GUNTER, Amy Elizabeth

1879 and enclosures to:

d. OTHER NAMES USED OR KNOWN BY. List all other names used

or known by. Each name entered will be identified as to type, e.g.:

Defense Security Service

Also Known As (AKA) - HAHN, Joseph A., Mrs.

P.O. Box 18585

Alias - GLADHILL, Christine

Baltimore, Maryland 21240-8585

e. DATE OF BIRTH. Enter subject's birth date in MM/DD/YYYY

format, e.g., March 13, 1948 would be 03/13/1948.

CONTRACTOR EMPLOYEES. This block MUST be left blank.

f. PLACE OF BIRTH. Enter city, county, and state (or country if not

The DD Form 1879 and enclosures must be sent to:

U.S.). Do not abbreviate City or Country.

Defense Security Service

9. U.S. CITIZENSHIP VERIFIED. If "Yes" is marked, indicate in

Defense Industrial Security Clearance Office

block 9.c. which document from the below list was reviewed for

P.O. Box 2499

verification. If U.S. Citizenship was verified in a previous

Columbus, Ohio 43216-5006

investigation, mark "Yes" and explain in 9.c. that citizenship has

been previously verified. If Naturalizaton Certificate was reviewed,

NOTE: This address must not be entered into block 5.b.

list, in block 9.c., the certificate number. If "No" is marked, explain

in Item 18 why citizenship was not verified.

6. DO YOU DESIRE ADVANCE NOTICE OF NAC RESULTS?

- Birth Certificate

MILITARY/U.S. GOVERNMENT EMPLOYEES. If advance notice

- Naturalization Certificate

of the NAC results is desired prior to the completion of the

- Citizenship Certificate

investigation, mark "Yes."

- Passport

CONTRACTOR EMPLOYEES. This item MUST be left blank.

- Report of Birth Abroad of a U.S. Citizen

DD FORM 1879, AUG 1999

FOR OFFICIAL USE ONLY (When filled in)

Page 3 of 4 Pages

FOR OFFICIAL USE ONLY (When filled in)

DETAILED INSTRUCTIONS (Continued)

10. LOCAL FILES VERIFICATION/PRE-SCREENING INTERVIEW.

16. REASON ACCESS TO CLASSIFIED INFORMATION OR

Include a review of appropriate indices and files maintained by or for

INVESTIGATION IS REQUIRED.

the military or employing agency/activity concerning its person- nel.

Examples are organization, management, and supervisor files;

MILITARY/U.S. GOVERNMENT EMPLOYEES. List unclassified

personnel, disciplinary, performance and counseling files; medical

description of duties which warrant access to classified information

files; special security and special program files; security, law en-

or which warrant the investigation.

forcement and intelligence indices or files (excluding state and local

CONTRACTOR EMPLOYEES. List unclassified description of

civilian law enforcement agencies); and legal and legal assistance

duties which warrant access to classified information or which

files (excluding statutorily restricted information). Included are files,

warrant the investigation. Also, the applicable contract number

forms or records executed by persons having knowledge of the

MUST be listed.

individual being considered for a personnel security investigation.

Local files include files maintained by other elements of a corpora-

17. HISTORY OF GOVERNMENT EMPLOYMENT AND/OR CURRENT

tion or its parent company in support of the employing entity.

MILITARY SERVICE INDICATED ON ATTACHED SF 85P/SF 86 IS:

a. TYPE.

MILITARY/U.S. GOVERNMENT EMPLOYEES. Complete as

MILITARY/U.S. GOVERNMENT EMPLOYEES. The review of

appropriate. If block 17.b. or 17.c. is marked, provide explanation

local files will be indicated by marks in the appropriate blocks. If a

in Item 18.

particular record was not reviewed, indicate, in Item 18, the reason

CONTRACTOR EMPLOYEES. This item MUST be left blank.

why and state where the record is located. Complete block (5) if an

Authorized Pre-Screening Interview was conducted; if not

18. REMARKS. Enter information necessary to clarify entries in

conducted when appropriate, indicate the reason in Item 18.

other items and to list additional information when there is

Complete block (6) if other records are reviewed that do not fall into

insufficient space. This item may be continued on plain bond paper

categories (1) through (5).

with a heading containing subject's name, Social Security Number,

CONTRACTOR EMPLOYEES. Mark blocks (1), (2), and (6), if

and the notation "Continuation Sheet - 1879."

appropriate. Also, mark block (3) if the information is available to

you; if not, so indicate. Do not mark blocks (4) or (5).

19. INVESTIGATION VALIDITY CERTIFICATION.

b. DATE REVIEWED/CONDUCTED. Enter date review was

completed for each record and, if applicable, date Pre-Screening

a. TYPED NAME OF CERTIFIER. Type full name of individual

Interview was conducted.

certifying validity of the request for investigation.

c. FILES VERIFICATION - UNFAVORABLE INFORMATION

CONTRACTOR EMPLOYEES. If the request is for a Top Secret

REVEALED.

MILITARY/U.S. GOVERNMENT EMPLOYEES. Mark as applicable

clearance, this individual must be the Facility Security Officer (FSO)

for each type of record and/or Pre-Screening Interview. If

or other OODEP. For all other requests, this individual must be the

unfavorable information is developed, provide pertinent details in

FSO or a designee.

Item 18.

CONTRACTOR EMPLOYEES. Mark as applicable for each type

b. TITLE OF CERTIFIER. List the title of individual certifying the

of record. If unfavorable information is developed, provide pertinent

request for investigation.

details in Item 18.

c. SIGNATURE OF CERTIFIER. Signature of individual authorized

11. PRIOR INVESTIGATION.

to request investigation.

MILITARY/U.S. GOVERNMENT EMPLOYEES, AND

CONTRACTOR EMPLOYEES. If "Yes," be sure that the type of

d. DATE SIGNED BY CERTIFIER. Enter the date this form is

investigation, date, who conducted the investigation, and the file

signed.

number are listed.

e. TELEPHONE NUMBER. List the telephone number, including

12. TITLE OR POSITION OF SUBJECT.

area code and/or Defense Switched Network (DSN) of the certifying

MILITARY OR U.S. GOVERNMENT EMPLOYEES. If military

official.

service member, list rank, service and write in "Military Applicant."

If U.S. Government Employee, list grade and write in "U.S.

20. EMPLOYEE'S IMMEDIATE SUPERVISOR'S CERTIFICATION.

Government Applicant."

If request is for an upgrading of a currently held clearance or for a

CONTRACTOR EMPLOYEES. List job title.

Periodic Reinvestigation (PR), the subject's immediate supervisor

MUST complete the certification. Certification by the immediate

13. TS BILLET NUMBER.

supervisor does not require review of the completed SF 85P/SF 86

MILITARY/U.S. GOVERNMENT EMPLOYEES. If request is for a

by the supervisor.

Top Secret clearance, list the Billet Number if such a system has

If the electronic DD Form 1879 is utilized, the requester must

been implemented.

retain an originally signed document from the employee's immediate

CONTRACTOR EMPLOYEES. This item should be left blank.

supervisor certifying the absence or presence of any adverse

14. ENCLOSURES. List and identify all enclosures attached to this

information. This documentation must be retained with a copy of

the electronically generated DD Form 1879, signed by the

form (i.e., SF 85P, SF 86, FD Form 258, copies of local files

requester, until the clearance process is complete. The employee's

verification, results of Pre-Screening Interview, etc.).

immediate supervisor documentation must contain the following:

15. RETURN RESULTS TO.

a. ADVERSE INFORMATION. Self-explanatory.

MILITARY PERSONNEL. Enter the name of the parent military

service which will adjudicate the investigation. NOTE: Investiga-

b. IMMEDIATE SUPERVISOR. Type full name of immediate

tions conducted on military personnel, who are assigned to a DoD

supervisor.

Component, will be returned only to the Subject's parent military

service for adjudication, regardless of the Component making the

c. TITLE. List the title of immediate supervisor.

original request. The adjudicating facility will then be responsible

for expeditiously transmitting the results of the clearance deter-

d. SIGNATURE. Signature of immediate supervisor.

mination to the Component who requested the investigation.

U.S. GOVERNMENT EMPLOYEES. Enter the name of the

e. DATE SIGNED. Enter the date this form is signed.

organization and mailing address that the investigation should be

sent to upon completion.

f. TELEPHONE NUMBER. List the telephone number, including

CONTRACTOR EMPLOYEES. This item MUST be left blank.

area code and/or DSN number of the immediate supervisor.

DD FORM 1879, AUG 1999

FOR OFFICIAL USE ONLY (When filled in)

Page 4 of 4 Pages