Pssq Form PDF Details

In today’s security-conscious environment, the necessity of exhaustive background checks cannot be overstated, especially within sectors that handle sensitive information. The Personnel Security Screening Questionnaire serves as a pivotal tool in this comprehensive vetting process, ensuring that individuals seeking positions which grant access to secret and controlled data are meticulously evaluated. This questionnaire, designed with thoroughness in mind, delves into a wide array of personal aspects—ranging from familial ties to foreign nations, past travels beyond the U.S. borders, and interactions with the legal system, to financial responsibility and mental health inquiries. Each section demands candor and completeness from the respondent, underlining the importance of honesty in potentially securing a position of trust within the government. Notably, the form underscores the legal protections and rights afforded to the individual, such as advisement under the Privacy Act of 1974 and the Fifth Amendment. As individuals navigate through the pre-screening interview and detailed personal inquiries, they are reminded of the gravity of false statements and the critical nature of their potential roles. The questionnaire acts not only as a filter for eligibility but also as a mirror reflecting the candidates' integrity and suitability for positions that require unwavering trustworthiness.

QuestionAnswer
Form NamePssq Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesinterview dob nrd pdf, personnel security questionnaire pssq, security pssq get, personnel questionnaire cnrc template

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PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONNEL SECURITY SCREENING QUESTIONNAIRE PRE SCREENING INTERVIEW

1.The purpose of this interview is to assist in determining your acceptability for nomination and further processing for access to secret and controlled information. You will be given the same Privacy Act advisement as was provided with the Questionnaire for National Security Positions (SF86). Questions asked during the course of this interview are of a personal nature. The interview provides an opportunity for you to present additional, pertinent information to that on the SF86. The pre-nomination interview protocol has been designed as a guide for the interviewer to obtain and record this supplementary information and to determine your eligibility for Navy ratings and programs that require a security clearance.

2.The Privacy Act of 1974 requires that you be told the following:

a. Executive Orders 10450, Security Requirements for Government Employees, and 12065, National Security Information, are the authorities for soliciting the information to be requested during the interview. Executive Orders 9497, numbering Systems for Federal Accounts Relating to Individual Persons, is also applicable since you are asked to provide your Social Security Number.

b. You are advised of your rights under the Fifth Amendment to the U.S. Constitution/Article 31 of the Uniform Code of Military Justice. Disclosure of information is voluntary, you need not answer any question. You may not be compelled to incriminate yourself or respond to a question whose answer might tend to incriminate you. You may consult an attorney. You may suspend or terminate the interview at any time. However, if you refuse to be interviewed or decline to provide information in response to specific, pertinent questions, the interview will be terminated and you will not be eligible to fill a position requiring access to secret or controlled information.

c. All information developed during the course of the interview shall be maintained in personnel security channels and made available only to those authorities who have a need-to-know in connection with the processing of your nomination for duties requiring access to secret or controlled information, or as otherwise authorized by Executive Order of statue.

3.You are reminded that a knowing and willful false statement on the SF86 can be punished by fine or imprisonment, or both. The interviewer will determine your acceptability for nomination to duties requiring access to secret and controlled information.

I understand the purpose of the interview. I have been advised of my rights as stated in paragraph 2b, above:

DOBDate

Signature of Nominee

Page 1 of 7

PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION

You are here today because you either enlisted with a guaranteed skills job or are being considered for one because of your qualifications. Since these jobs involve matters of national security, it is imperative that you answer the questions on this questionnaire honestly. Your answers to these questions will determine how extensive your interview will be when you are called.

PERSONAL INFORMATION

Yes

No

 

 

 

1. Are you, any of your family members and/or anyone you have lived with, not a citizen of the U.S.?

2. Were any of your family members born outside the U.S.? Does not include births abroad of U.S. parents.

3. Do you have any friends, relatives or know persons who are U.S. citizens that live outside of the U.S.?

4. Do you or any family members maintain or claim dual citizenship with a country other than the U.S.?

5. Have you ever traveled outside of the U.S., including Canada or Mexico, for any purpose?

6. Do you have any friends or relatives that are involved in any criminal misdemeanor and felony activities?

7. Do you have any friends or relatives that are presently in jail, prison, parole or probation?

8. Have you ever been rejected by any branch of the armed forces for enlistment or affiliation due to any reason other than medical?

9. Have you ever been charged or punished under the UCMJ, received non-judicial punishment, been convicted by a military court, investigated by a military agency, relieved of duties or had adverse entries in your service record or on your evaluations or recruit hard card?

10. Have you ever been fired from a job?

11. Have you ever left a job under other than favorable conditions (left due to allegations of misconduct or bad performance)?

12. During high school or college, were you ever suspended, expelled, or disciplined for any reason?

13. Have you ever had any bills turned over to a collection agency?

14. Have you ever paid a bill more than 30 days late or not at all?

15. Have you ever bounced a check, overdrawn your debit card, had a credit card recalled, anything repossessed or voluntarily surrendered to a creditor?

16. Have you ever filed for bankruptcy?

17. Have you ever had debt judgments or liens filed against you?

18. Do you owe any individual or persons money, for any reason?

19. Does your monthly payment debt (i.e. credit cards, car payments, insurance, medical bills, record/health/book clubs, etc.) exceed 50 percent of your monthly income?

20. Have you ever received an Other Than Honorable discharge from any branch of the military?

21. Have you ever shoplifted or stolen anything, whether charged or not?

22. Have you ever been charged with or convicted of a felony, misdemeanor, or any offense other than traffic violations (whether the charges were dropped or not)?

23. Are there any charges pending against you now?

24. Have you ever used, bought, sold, grown, manufactured or possessed marijuana?

25. Have you ever used, possessed or experimented with any type of controlled substance, narcotic or drug, other than marijuana?

26. Have you ever taken someone else’s prescription medication.

27. Have you ever been convicted of an alcohol related offense?

28. Have you ever been told to enter, or have you ever been in an alcohol or drug program?

Page 2 of 7

PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL INFORMATION (CONT)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

29. Have you ever been arrested, cited, fired, or reprimanded because of your use of alcohol?

30. Have you ever been seen by or consulted with a mental health professional, counselor, psychologist or psychiatrist for any reason?

31. Have you ever been hypnotized?

32. Have you ever suffered from dizziness, loss of consciousness, blackouts, been knocked out, fainted, or had any head injuries?

33. Have you ever had serious thoughts about suicide or have you attempted suicide?

34. Have you ever been treated for anxiety, depression or stress?

35. Have you ever been involved in any deviant sexual behavior?

36. Have you ever destroyed or vandalized any property or possessions of others?

37. Have you ever been charged or convicted of a firearms, weapons, or explosives offense?

38. Have you ever done anything in your lifetime someone might blackmail you with, such as engaged in extra-marital affairs, undetected theft, fraud, embezzlement, etc.?

39. Has anyone at anytime told you or suggested that you withhold or not reveal any information about yourself?

40. Is there anything that we have not asked you or that you have not told us that could possibly come up during an investigation that could cause you a problem?

ALL "YES" ANSWERS MUST BE EXPLAINED IN DETAIL IN THIS SECTION.

The answers I have provided are true, complete, and correct to the best of my knowledge and

belief. I have not intentionally provided any incorrect or misleading information.

Signature

Page 3 of 7

PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICE INVOLVEMENT

41.List every time you have been stopped detained, held, ticketed, arrested, warned or questioned by the police for any reason, whether charged or not, or told it was expunged, in chronological order.

DATE

PLACE

CITY/STATE

OFFENSE

FINAL DISPOSITION/ FINED AMOUNT/ DISMISSED/TRAFFIC SCHOOL/ETC.)

The answers I have provided are true, complete, and correct to the best of my knowledge and

belief. I have not intentionally provided any incorrect or misleading information.

Signature

Page 4 of 7

PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL STATEMENT

This form is to be completed by all candidates who require an eligibility interview for an SSBI or entry into a rating/program that requires a security clearance.

Recruiter

 

 

Classifier

District

 

 

MEPS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

42. Have you filed federal income tax returns every year that you worked and should have filed a return?

If No, Explain

43. Have you filed state income tax returns every year that you worked and should have filed a return (provided the state you are from has a state tax)?

If No, Explain

44. Do you have overdue federal and/or state taxes from past years?

If yes, list

Amount Owed

Status

Year Owed

To What Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

45.List any amounts owed to anyone including, but not limited to, banks, credit unions, stores, schools, charge cards, utilities, landlords, personal loans, student loans, debt-consolidation loans, etc. (Do not list your savings and/or checking account or insurance payments.)

Full Name of Financial Institute

(company)

Balance on Account

Monthly Payment

Date of Most Recent

Payment

The answers I have provided are true, complete, and correct to the best of my knowledge and

belief. I have not intentionally provided any incorrect or misleading information.

Signature

Page 5 of 7

PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL STATEMENT (CONT)

Yes

46. Have you ever filed or declared bankruptcy?

If yes, show type, court where filed, amount involved and/or status of debts.

47. Have you ever had anything repossessed or have you ever voluntarily surrendered any item?

If yes, describe item involved, date of repossession/surrender, monthly payment,balanced owed, and number of months behind when repossessed/surrendered.

48. Have you ever had any debts turned over to a collection agency?

If yes, show account number, agency name, location, balance, months behind when debt assigned to collection agency, and current amount owed.

I certify that the above is a true statement of my financial status.

Signature

Date

No

Page 6 of 7

PERSONNEL SECURITY SCREENING QUESTIONNAIRE

Name

 

DOB

 

NRD:

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTERVIEWER'S COMMENTS

Item Number

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

INTERVIEWERS PRINTED NAME

TITLE/POSITION:

 

 

 

 

 

 

Based on the applicants responses to this questionnaire and my interview, I have determined the applicant is (qualified / not qualified) for entry into the

Q

NQ

Rating/Program

Rating Security Manager contacted on

Applicant is

APPROVED

DISAPPROVED

RATING SECURUITY MANAGER NOT CONTACTED

Interviewers Signature , Date and Contact Phone Number

Signature

Date

Phone Number

RETAIN A COPY OF THE PSSQ IN THE APPLICANT’S RESIDUAL FILE

Page 7 of 7

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2. Once your current task is complete, take the next step – fill out all of these fields - I understand the purpose of the, Signature of Nominee, DOB, and Date with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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It's simple to make an error while filling in the I understand the purpose of the, thus you'll want to go through it again prior to deciding to send it in.

3. Completing Name, DOB, NRD, Date, You are here today because you, INTRODUCTION, PERSONAL INFORMATION, Yes, Are you any of your family, Were any of your family members, Do you have any friends relatives, Do you or any family members, Have you ever traveled outside of, Do you have any friends or, and Do you have any friends or is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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4. Filling out Have you ever been fired from a, Have you ever left a job under, During high school or college, Have you ever had any bills, Have you ever paid a bill more, Have you ever bounced a check, Have you ever filed for bankruptcy, Have you ever had debt judgments, Do you owe any individual or, Does your monthly payment debt ie, Have you ever received an Other, Have you ever shoplifted or, Have you ever been charged with, Are there any charges pending, and Have you ever used bought sold is crucial in this next form section - make certain that you spend some time and fill out each blank!

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5. Last of all, the following last section is what you have to complete prior to submitting the form. The fields in question include the following: Have you ever used bought sold, Have you ever used possessed or, Have you ever taken someone elses, Have you ever been convicted of, Have you ever been told to enter, and Page of.

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