Dhs Form 11052 1 PDF Details

The Department of Homeland Security (DHS) DHS 11052-1 form serves a critical function in managing and processing access requests from foreign nationals seeking to visit DHS facilities or personnel. Designed to enhance security measures and streamline the visitation process, this form requires submission by visitor hosts to designated DHS element Foreign Visit representatives well in advance of the proposed visit—30 days for visits and 60 days for assignments extending beyond 31 days. A comprehensive overview of the visitor's personal and professional background is needed, highlighting the importance of detailed information collection including citizenship status, employment details, and the specific purpose of the visit. Additionally, the form encompasses protocols when the sharing of classified information might occur, necessitating prior clearance from a DHS Foreign Disclosure Officer. This ensures both the security of sensitive information and adherence to regulatory compliance. Furthermore, it encapsulates a broad spectrum of data collection from basic visitor information to specifics about the visitation schedule and the nature of the engagement, illustrating the depth of scrutiny and preparation involved in hosting foreign nationals within DHS-affiliated environments. The form thus encapsulates a meticulous approach to security and operational efficiency within the Department of Homeland Security, underscoring the importance of thorough vetting in safeguarding national interests.

QuestionAnswer
Form NameDhs Form 11052 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdhs foreign national request form, sota program nyc dhs, dhs national visitor request get, 11052 form

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DEPARTMENT OF HOMELAND SECURITY

FOREIGN NATIONAL VISITOR ACCESS REQUEST

INSTRUCTIONS

In order to support visits by foreign nationals to DHS facilities and personnel, visitor hosts shall submit this form to DHS element Foreign Visit representatives (per element Foreign Visit Procedures) 30 days in advance of a visit (30 days or less) or 60 days in advance of an assignment (31 days or more). For purposes of this form, a foreign national is defined as a person who is not a citizen or national of the United States. This form shall be filled out for each visitor (including drivers, interpreters, etc.) and each program to be visited. Visitor hosts shall be notified upon approval or disapproval of the visit. If the visit may involve sharing or disclosure of classified information, the host must contact the DHS Foreign Disclosure Officer prior to the visit for guidance.

FOREIGN VISITOR INFORMATION

NAME OF VISITOR (LAST, FIRST, MIDDLE)

GENDER

DATE OF BIRTH (MM-DD-YY)

CITY AND COUNTRY OF BIRTH

COUNTRY(IES) OF CITIZENSHIP

GREEN CARD

Yes No

GREEN CARD EXPIRATION DATE (MM-DD-YY)

LAWFUL PERMANENT RESIDENT NUMBER

SOCIAL SECURITY NUMBER

VISA TYPE

VISA NUMBER

VISA EXPIRATION DATE (MM-DD-YY)

PASSPORT COUNTRY OF ISSUE

PASSPORT NUMBER

PASSPORT EXPIRATION DATE (MM-DD-YY)

CURRENT EMPLOYER / DIVISION / OFFICE

TYPE OF BUSINESS/ORGANIZATION

EMPLOYER ADDRESS (STREET, CITY, STATE, ZIP CODE, COUNTRY)

EMPLOYER PHONE NUMBER

VISITOR JOB TITLE / POSITION

VISITOR CONTACT NUMBER

VISIT INFORMATION

DATE OF REQUEST N/A

DHS VISITOR HOST NAME (LAST, FIRST MIDDLE)

NCBRT eLearning

HOST ORGANIZATION (ELEMENT,DIVISION,OFFICE)

National Center for Biomedical Research and Training

HOST PHONE NUMBER

HOST E-MAIL ADDRESS

HOST FAX

1-866-221-1083

elearn@ncbrt.lsu.edu

225-578-8973

 

 

 

VISIT START DATE

VISIT END DATE

NUMBER OF DAYS ON SITE

N/A

N/A

N/A

 

 

 

UNCLASSIFIED DESCRIPTION OF VISIT PURPOSE / SUBJECTS TO BE DISCUSSED / INTERNATIONAL AGREEMENTS

Online Training to enhance level of awareness and capacity to respond.

FULL NAME OF ORGANIZATION AND PROGRAM TO BE VISITED

National Center for Biomedical Research and Training

FACILITIES TO BE VISITED (INCLUDE BUILDING NAME/NUMBER, ADDRESS, ROOM NUMBERS, AND HIGHEST LEVEL OF CLASSIFICATION FOR WHICH THE FACILITY IS ACCREDITED – UNCLASSIFIED, SECRET, SCI,)

N/A

REMARKS (COORDINATION / SPECIAL REQUIREMENTS)

N/A

REVIEWS

DHS Form 11052-1 (07/05)

FOREIGN VISIT COORDINATOR

DATE

PHONE

FAX

N/A

N/A

N/A

N/A

 

 

 

 

E-MAIL

COMMENTS

 

 

N/A

N/A

 

 

 

 

 

 

INTERNAL SECURITY REP

DATE

PHONE

FAX

N/A

N/A

N/A

N/A

 

 

 

 

E-MAIL

COMMENTS

 

 

N/A

N/A

 

 

 

 

 

 

APPROVAL AUTHORITY

DATE

PHONE

FAX

N/A

N/A

N/A

N/A

 

 

 

 

E-MAIL

COMMENTS

 

 

N/A

N/A

 

 

 

 

 

 

OTHER REVIEWER

DATE

PHONE

FAX

 

N/A

N/A

N/A

N/A

 

 

 

 

 

 

 

E-MAIL

COMMENTS

 

 

N/A

N/A

 

 

 

 

 

 

OTHER REVIEWER

DATE

PHONE

FAX

 

N/A

N/A

N/A

N/A

 

 

 

 

 

 

 

E-MAIL

COMMENTS

 

 

N/A

N/A

 

 

 

 

 

 

PRIVACY ACT STATEMENT: The Privacy Act, 552a, requires that federal agencies inform individuals, at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. The collection of this information is authorized by EO 9397, 6 USC 341, 44 USC 3101, and EO 12958. Provision of the information concerning foreign visits is mandatory under the provisions of EO 12958. Failure to provide it may impact planned visits. Use of this information is for internal purposes to facilitate visitor processing.

DHS Form 11052-1 (07/05)

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