How to Certify a Security Clearance to Another Agency
Updated 03/14/02

(Sample)

A "Visitation Authorization and Security Clearance Certification Request", form CD-414, must be initiated by ITA employees whenever they plan to visit other government agencies or facilities in the United States where national security information is to be discussed or handled. This form must be completed by the visitor and the security office, signed by the supervisor and the security officer, and forwarded to the visit site at least 10 working days prior to the visit or period of certification. The form must be typed. The form is available in Delrina Form Flow as CD 414. A complete sample is attached.

The employee (visitor) should complete the following blocks on the CD-414:

1. TO: (Complete Name, Organization, Address, Phone/FAX numbers of person to be visited)

2. FROM: (Requestor's Name, Organization, Address, and Phone/FAX numbers)

3. VISITOR(S) NAME: Last, First, Middle Initial, and Social Security Number

DATE and PLACE of BIRTH (list city and state, or city and country)

COURIER: If applicable, list Courier Authorization Card (CD-75) number

4. The Security Office will complete ITEM 4 of the CD-414.

5. PURPOSE of VISIT: (Include reason for needing access to classified material)

6. DATE(S) of VISIT or CERTIFICATION: (Not to exceed one year)

7. REQUIRED LEVEL of CLEARANCE: (e.g., confidential, secret or top secret)

8. POINT(S) of CONTACT: Who in the other agency needs the security clearance data? A: Name; B: Organization; C: Phone Number; D: Fax. No.

9. REMARKS: (If applicable - Any additional information related to the visit)

10. REQUESTOR: (Name of individual requesting visit authorization)

Office/Division (of requestor)

Date (Date form is completed)

11. NEED TO KNOW CERTIFICATION: (Must Be Completed by Immediate Supervisor) : to include Signature, Name/Title and Date/Phone number

Upon completion by the supervisor, the CD-414 should be submitted to the security staff in room 1066.

The security staff will complete ITEM s 12 of the CD-414.

Upon completion of the CD-414, the security staff will forward it to the appropriate agency, return a copy to the requestor and file a copy.

For additional information contact: Security Staff at 202-482-8355.

See attached