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FOREIGN CONTACT QUESTIONNAIRE

Employees holding access to Sensitive Compartmented Information (SCI) are required to report any close and continuing contact with foreign nationals. Complete a separate form for each contact. Fax this completed form to the Personnel & Document Security Division at 202/720-1689.

You do NOT need to report:

o Limited contact with foreign national neighbors, teachers, and tradesmen

o Contact with foreign nationals as a result of official US government business

You DO need to report:

o Personal and/or intimate relationship(s) with non-U.S. citizens

o (Outside Employment) Professional relationship with a foreign national

o Foreign national domestic help that has unescorted access to your home

o Any situation in which you believe you are being targeted by a foreign government

(Please use additional paper, as needed, to adequately address the questions.)

EMPLOYEE INFORMATION

Full Name:      

Agency:      

Position Title:      

Work Telephone:      

FOREIGN NATIONAL INFORMATION (Complete to the best of your ability)

Full Name:      

Other Names Used:      

Gender: Male Female

Date of Birth/Approximate Age:      

Nationality/Citizenship (Include Dual):      

Current Address:      

     

Phone Number and Email Address:      

Profession/Affiliation:      

NATURE OF CONTACT INFORMATION

1. How was the contact initiated?      

2. When did contact first occur and what are the future contact plans (correspondence, email, visits, etc.)?      

3. Where did contact occur?      

4. Describe the relationship (social, business, intimate, family, etc.):      

5. Do you have any relatives or friends in this person’s country?      

6. Describe any government, political, military, or intelligence affiliation this person holds:      

7. Did the individual ask you where you work?      

8. Did the individual ask what type of work you do?      

9. Did the individual seem to control the direction of the conversation?      

10. Did you discuss involvement in government related activities and/or have you been asked by this person or their associates to perform any task or service?      

11. Did the individual express an interest in classified, sensitive, or proprietary information? If yes, identify those topics or technologies.      

12. Did the individual request any USDA open source material? If so, what was requested and did you provide it?      

13. Did the individual ask about your political affiliations?      

14. Did you or have you received any gifts from the foreign national?      

15. Did the individual offer to arrange for any special treatment?      

16. Did the individual offer to pay for anything (meals, transportation, gifts, etc.)?      

17. Did you exchange business cards, telephone numbers, or addresses?      

18. Describe any known participation or financial support to organizations that seek to change U.S. government policy by force or violence:      

19. To the best of your knowledge, describe the physical characteristics of the individual (age, height, weight, hair color, eye color, complexion, mark, scars, tattoos, etc.)      

20. Add any additional comments you feel are necessary.      

____________________________ __________________

Signature of Employee Date

For Agency Use Only:

Subject’s SSN:

Information sent to CIB on ___________.

(date)

-----------------------

United States

Department of

Agriculture

Office of the

Assistant Secretary

For Administration

Office of Homeland Security and Emergency Coordination

Personnel and Document Security Division

Mail Stop 5050

1400 Independence

Avenue SW

Washington, DC

20250-5050

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