Msfc Form 383 1 – Fill Out and Use This PDF

UUPIC LOOKUP

CONTRACTOR EMPLOYEE CLEARANCE DOCUMENT

OITM/ITM LOOKUP

(See Instructions)

NAME OF INDIVIDUAL:

BADGE NUMBER:

UUPIC NUMBER:

EFFECTIVE DATE:

LAST DAY ON DUTY:

OTHER NAME USED:

REASON FOR LEAVING

Resignation

Reduction in Force

Sick Leave/Long-Term Disability

CONTRACTOR ORGANIZATION AND ADDRESS:

Retirement

Termination

Term/Contract Expired

Transfer

Suspension

Deceased

Military

LWOP

ITEM CLEARED

TO BE CLEARED WITH

SIGNATURE OR NAME OF RESP.

SIGNATURE OF

CLEARING AUTHORITY

COMPANY REPRESENTATIVE

Disposition of Electronic and Hardcopy Files

Disposition of Registered Documents and

1.

Classified Materials

Supervisor

Employee Must Clear

Disposition of Official Records

Disposition of Chemicals

Redstone Scientific Information Center

2.

RSIC Technical Documents

Bldg 4484, 3rd Floor

256-876-5181

MSFC Respirator Services

3.

Respiratory Equipment

Bldg 4646, 256-544-4483 or

256-544-4484

4.

Small Tool Control System

Machining and Assembly Branch

Bldg 4705

Disposition of ODIN Seats (MAMs)

5.

Disposition of Non-ODIN Property

ITM/OITM

Employee Must Clear

(Use button at top right for list)

ODIN Cell Phones, Pagers, PDAs

Computer Access

Devices to be turned in here

Office of the CIO, IS01

Employee Must Clear

6.

Secure ID Token

Bldg 4200, Rm 522A or Rm 526

Long Distance Calling Cards

256-544-2847 or 256-544-5532

Telephone Listing Data (MSFC Form 2683)

7.

Property Management/Government Property

Bldg 4200, Rm 410

Employee Must Clear

256-544-2293

8.

MSFC Medical Center

MSFC Medical Center

Employee Must Clear

Bldg 4249, 256-544-2390

9.

Security Keys

Organizational Lock and

Employee Must Clear

Key Coordinator

Security

Protective Services Department, AS50

Badge

KeyCard

10.

256-544-2090, Bldg 4312

Employee Must Clear

Vehicle Decal

PKI/Entrust

(See Instructions)

COMPANY USE

12.

13.

14.

15.

I certify that all Government property issued to me has been turned in, accounted for, or

SIGNATURE OF EMPLOYEE:

adjustment made; that all funds advanced to me have been returned, repaid, or adjustment

made; that obligated service agreements have been completed or a waiver has been

approved; that all computer materials and programs or copies have been turned in; and

that I have no Government property or materials in my possession.

MSFC Form 383-1 (March 2012)

PREVIOUS VERSIONS OBSOLETE

INSTRUCTIONS FOR COMPLETING

MSFC FORM 383-1

CONTRACTOR EMPLOYEE CLEARANCE DOCUMENT

The Contractor Employee Clearance Document (MSFC Form 383-1) must be completed for contractor employees who leave the employment of their company for more than 30 days.

Controlled items are: (1) keys, property, classified documents, and other items that must be signed for by an individual; or (2) ADP programs, documentation, tapes, data in machine-readable form, magnetic disks or diskettes, proprietary software, tape cassettes,CDs, DVDs, flash drives, hard drives, or any other medium containing classified, sensitive, or proprietary data and other ADP hardware and software used by specified individuals and (3) those items which if lost, allowed to be used by or made available to nonauthorized personnel could cause embarrassment to or create a compromising situation with a Government function or operation.

Item 1. Your supervisor must sign as clearing official. By signing this block, the supervisor and administrative officer are certifying that any records the employee had (or was responsible for, etc.) were properly transferred to another appointed employee, or to their supervisor to reassign, retire, etc. This includes records that may be in hardcopy (files) or electronic (on electronic equipment such as PDAs, laptops/desktops, servers, etc., or offline storage such as CDs/DVDs, thumb drives, hard drives, etc.). It is understood that the ID(s) of the departing user will be deleted upon transfer or termination, in accordance with MPR 2810.1. Your supervisor must clear Disposition of all Registered Documents, Classified Materials, Official Records, and Chemicals.

Item 5. You are responsible to ensure all property assigned to you in N-PROP and MAMs has been dispositioned. Your Organizational IT Manager (OITM) must sign as the clearing official. By signing this block, the OITM and your Supervisor (in ITEM 1) are certifying that any records the employee had (or was responsible for, etc.) were properly transferred to another appointed employee or to their supervisor and all data that remains can be removed from the assigned equipment. All ODIN and non-ODIN property has been transferred to another appointed employee or an excess request has been submitted. This includes PDAs, pagers, laptops/desktops, peripherals, servers, network drops, etc.

Item 7. If charged with property, you are responsible that it is turned in, transferred to another person, or appropriate adjustments are made with the Logistics Services Department and with your organizational property manager when changed to a position no longer requiring the property or prior to leaving the Center. Employees must provide their badge number when clearing in Building 4200.

Item 9. Each laboratory/program/project office has a Lock and Key Coordinator. Contractors must clear with the Lock and Key Coordinator for the organization they support.

Item 10. When leaving the Center, you must personally turn in your NASA identification badge and car decal(s) to the Protective Services Identification and Registration Office (I&R), Building 4312. Remove decals from all of your vehicles and have them with you when you check out. If you do not know how many decals have been charged to you, call the I&R office at 256-544-2090. If you have Entrust/PKI, submit request through IDMAX

<https://idmax.nasa.gov/ > to modify PKI application and request revocation.

WHEN INFORMATION ENTERED

SUBJECT TO PRIVACY ACT OF 1974

When not under the continuing control and supervision of a person authorized access to

this material, it must be as a minimum, maintained under locked conditions.

Page 2 of MSFC Form 383-1 (March 2012)