WHCA Form 89 Security Screening Questionnaire

W HITE HOUSE COMMUNICATIONS AGENCY

SECURITY SCREENING QUESTION­NAIRE (SSQ)

Code:_________________ Date Reviewed:_______________ Initials_________________

Current Clearance: Secret TS Clearance Date:______________ Projected Investigation: SSBI PR

LAST NAME: FIRST: MI:_______

SSN: DATE OF BIRTH: (Month/Day/Year):

PLACE OF BIRTH: MOS/AFSC/RATE:

BRANCH OF SERVICE: RANK/PAY GRADE: /

DELAYED ENTRY DATE:_____________________ BASIC ACTIVE SERVICE DATE:___________________

(Year/Month/Day) (Year/Month/Day)

CURRENT ADDRESS:

CITY: STATE: ZIP:

PHONE# HOME: WORK: FAX:

E-MAIL ADDRESS:

Have you been interviewed for an assignment or ever been assigned to the White House Communications Agency in the past? YES____ NO_____

PRIVACY ACT OF 1974 (ADVISEMENT STATEMENT): The Authorities for requesting the following information are Executive Orders 10450, 11652 and 9397. The requested information is used in making security determi­na­tions, granting access to classified informa­tion, and making personnel management decisions. Routine uses include determin­ing the scope and coverage of a personnel securi­ty investigation, checking investiga­tive leads assuring complete­ness of the investigation, and providing evalua­tors and/or adjudicators with basic personal history information relevant to security and suit­ability. Informa­tion may be disclosed to and maintained by Govern­ment agencies and adminis­tra­tive personnel involved in processing security actions that evolve during the course of these determi­nations.

GENERAL INFORMATION CONCERNING THIS PACKAGE: Completion of this questionnaire represents a security screening by representatives of the WHCA Security Office. Please NOTE: This questionnaire covers LIFE, not simply the last 5 to 10 years of your history. If favorably reviewed and you become selected for a WHCA position, additional security screening may follow, including a detailed single scope background investigation (SSBI) conducted by the Defense Security Service (DSS) or Office of Personnel Management (OPM). This investigation encom­passes extensive checks with appropriate law enforce­ment agencies, credit and financial institutions, schoolteachers and adminis­trators, friends, neigh­bors, employers and other persons who know and are willing to provide informa­tion about you. Upon completion of all screening and investigations, a determination will be made concerning your eligibility for Presidential Support Duty (PSD). BE ADVISED, falsification of this questionnaire may result in denial of PSD, denial or revocation of a security clear­ance or access to sensitive information, or possible separation from the military service. DISREGARD ANY ADVICE YOU MAY HAVE RECEIVED CONCERNING THE WITHHOLDING OF INFORMATION. It is in your best interest to complete all questions honestly and accurately by selecting the appropriate "YES" or "NO" response. For any "YES" answer, briefly explain your answer on the last page.

DISCLOSURE: Voluntary; however, if WHCA does not receive this information, the member will not be considered for Presidential Support Duty.

____________________________________________________

(Applicant’s Signature and Date)

WHCA SECURITY SCREENING QUESTION­NAIRE (SSQ)

The SSQ covers LIFE (NOT simply the last 5 – 10 years)

(Answering “YES” to any question(s) must be explained in the

REMARKS section found at the end of this questionnaire)

Loyalty and Character

Yes

No

1. Have you ever committed or attempted to commit sabotage, espionage, treason, terrorism, or sedition?

2. Have you ever knowingly established an association with a spy, terrorist, traitor, espionage agent, or representative of a foreign nation whose views or beliefs are contrary to the interests of the United States?

3. Have you (or persons associated with you) ever advocated the use of force or violence to overthrow the Government of the United States?

4. Have you ever expressed (verbally or in writing) a preference or allegiance to another country?

Foreign Relationships, Travel, Assets, Associations and Relatives

Yes

No

5. Do you have parent(s), brother(s), sister(s), spouse, children or significant friends residing in a nation whose interests may be opposed to the interests of the United States?

6. Do you have immediate family members who are citizens of another country or do you maintain a close personal relationship with a citizen of another country (i.e., cohabitate with, date, routinely communicate with, etc)?

7. Have you ever traveled to any country outside of the U.S. official or unofficial? Where there any lasting relationships (continued contact via telephone, email, social networks)? Please list all foreign travel to include length and purpose.

8. Do you own (fully or partially) any assets in a foreign country?

Falsification of Information

Yes

No

9. Have you ever mistakenly or deliberately misrepresented, falsified, or omitted significant information from a Personnel Security Questionnaire, a personnel qualifications statement, a personnel security interview, or official correspondence?

Security Violations

Yes

No

10. Have you ever failed to protect or safeguard classified information or material?

11. Have you ever been counseled or charged (verbally or written) with violating a security regulation or security procedure?

12. Have you ever disclosed classified information to a person unauthorized to receive such information?

Emotional and Mental Disorders

Yes

No

13. Do you have an illness or mental condition of a nature which, in the opinion of a board-certified psychiatrist, other licensed physician or a licensed clinical psychologist, causes, or may cause, a defect in judgment or reliability?

14. Have you ever been counseled in the past for mental, marital, emotional, stress, behavioral, or performance related problems?

Undesirable Character Traits

Yes

No

15. If we were to interview friends, family, supervisors, or co-workers, would any of them accuse you of engaging in any unusual conduct or behavior which would show that you are not honest, reliable, or trustworthy?

16. Would anyone we interview reference your security clearance tell us you may be subject to pressure, coercion, exploitation, or duress which may cause you to act contrary to the best interests of national security? Such conduct or circumstances may include: criminal behavior, a pattern of financial irresponsibility, blackmail, or violations of any military of government regulations.

17. If we were to interview friends, family, supervisors, or co-workers, would any of them say you have displayed poor judgment, you were unreliable, or that you are untrustworthy?

18. Have you ever been counseled by supervisors or co-workers for poor work performance or received unfavorable actions based on an unsatisfactory efficiency report?

19. Have you ever been forced to resign or asked to resign in lieu of termination?

20. Would a check of your employment history have any derogatory comments from supervisors or coworkers?

Financial Irresponsibility

Yes

No

21. Do you currently have financial difficulties or problems meeting your financial obligations?

22. Have you ever defaulted on a loan or had a debt turned over to a credit collection agency?

23. Would a credit search of your records reveal late payments or financial difficulties (such as but not limited to bankruptcy, foreclosure, repossession, etc.)?

24. Have you filed your taxes every year? Have you ever been notified by the IRS in regards to failing to file your taxes?

25. Have you ever been charged informally or formal about misuse of a Government or Cooperate Credit Card?

Moral Conduct

Yes

No

26. Have you ever been involved in or suspected/accused of child molesting, adultery, rape, indecent exposure, child/spouse abuse, prostitution, sexual harassment or group sex?

27. Have you participated in any conduct that could cause embarrassment to you or your family, or which could cause you to be blackmailed if such conduct were uncovered?

28. Have the police ever come to your home or interviewed you for any reason involving a moral issue or an allegation of a violation of local, state, and/or federal law?

Record of Law Violation

Yes

No

29. Have you ever been suspected of, accused, charged, placed on probation (to include academic probation) or prosecuted with any law violation*, including, but not limited to:

Writing bad checks	Vandalism
Failure to pay alimony or child support	Disturbing the peace
Shoplifting or theft	Misdemeanor or felony traffic violations
Disorderly conduct	Vagrancy
Malicious mischief	Trespassing or hunting violation
Breaking and entering	Misuse of identification
Drinking underage	Illegal possession of weapon
Curfew violation	Contributing to delinquency of minor
Any Misdemeanor or felony	Convicted of a courts-martial or serious UCMJ offense

* Answering YES to any law violations must be explained in the Remarks section.

Alcohol Usage and Abuse

Yes

No

30. Do you drink alcoholic beverages? If you answer is YES, circle one choice from each column to reflect your frequency of alcohol use:

1 - 3 drinks Daily

4 - 6 drinks Every other day

7 - 11 drinks Three times weekly

12 + drinks Weekly

Twice monthly

Monthly

31. Have you been or are you a user of alcohol habitually to excess or have you been diagnosed by a board-certified psychiatrist, other licensed physician or a licensed clinical psychologist as alcohol dependent or as suffering from alcohol abuse.

32. Have you ever been formally or informally counseled concerning your drinking habits?

33. Have you ever been involuntarily referred to an alcohol treatment program?

34. Have you ever lost consciousness or could not recall your actions after drinking alcohol?

35. Have you ever been cited, charged, accused, or prosecuted for DUI or DWI?

36. Have you ever had a charge of DUI or DWI downgraded to a lesser charge?

37. Have you ever been cited, detained, arrested, or charged with a crime involving alcohol?

Illegal Drugs and Drug Abuse

Yes

No

38. Have you ever used or experimented with, even one time, an illegal drug (except as prescribed or administered by a physician licensed to dispense drugs in the practice of medicine, or as otherwise authorized by law) such as but not limited to:

Cannabis (marijuana, tetrahydrocannabinol (THC), hashish)

Cocaine (crack, opium)

Depressants (barbiturates, methaqualone)

Hallucinogens (ecstasy, LSD, mescaline)

Narcotics (heroin, morphine, opium)

39. Have you ever abused prescribed and/or over the counter medication?

40. Have you ever taken another person’s prescribed medication?

41. Have you ever been cited, charged with, trafficked in, transferred, possessed, or prosecuted for the possession, sale, and/or use of illegal drugs?

HAVE YOU ANSWERED ALL THE PREVIOUS QUESTIONS HONESTLY? (INITIAL THE CORRECT RESPONSE) _____ YES _____ NO

READ AND SIGN BELOW:

I certify that I have read and understand the advisement statements listed on the cover page of this packet, and that the answers on this packet are true, complete and correct to the best of my knowledge, memory and belief. I understand that willfully making false statements or omissions of pertinent information may result in my not receiving a security clearance, Sensitive Compartmented Information access, or approval for Presidential Support Duty and further that such actions may result in punishment under the UCMJ and/or separation from military service.

I further understand that I am obligated to inform the Interview­er or the WHCA security representative of any substantial change which occur and any changes which may alter the results of this security screening.

***CREDIT CHECK AUTHORIZATION***: I hereby authorize the Security representatives for WHCA to obtain my credit information for the purpose of determining my eligibility for Presidential Support Duty. ______(Initials)

_______________________________________ ___________________________________

Printed Full Name (Last, First, MI) Applicant's Signature

______________

Date

* *************************************************************************************************************

FOR INTERVIEWER USE ONLY

I certify that the interview conducted on __________________ at _______________________

(Date) (Location)

was conducted in a fair and impartial manner. Applicant was given ample opportunity to explain any issues that were disclosed. The interview notes and credit report are attached. _________(initials).

__________________________________ ___________________________________

Printed Name of Interviewer Signature of Interview

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-TBD). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

REMARKS: Use this page if you need additional space to explain your “YES” answers.

Question No. Remarks

7

FOR OFFICIAL USE ONLY

WHCA Form 89 OMB No. 0000-0000

1 November 2011 - Previous versions are obsolete OMB Approval Expires 1 Dec 2016

(WHEN FILLED IN)