SSN Justification for Police Record Check

SECNAV RCS 5213/1 (Effective 11/1/2016 through 11/31/2019)
GENADMIN DON CIO WASHINGTON DC 192101Z REV 10/2016

SSN REDUCTION REVIEW
DATE COMPLETED:

EMAIL
SUBMIT
Form Number:

Submission for (Check one):

FORM

IT SYSTEM

USNA 5500/1

Form Revision Date:

26 Sep 2018

SHARE DRIVE / WEB PORTAL

Requiring Document: 10

U.S.C. 6958

12-16
SECTION 1

TO BE COMPLETED BY FORM ORIGINATOR/SPONSOR. Forms that collect and retrieve by SSN/PII must be covered by a System of Record
Notice (SORN), be call for within a requiring document, and have Privacy Act Officer approval for Privacy Act Statements. Return
completed packages that contain the SSN Reduction Review Form, Justification, and if need the DD 67 to the
cognizant forms manager.
1. Is the form covered by a System of Record Notice (SORN)?
a. If yes, what is the SORN number?
N01531-1

YES

NO

b. If no, contact the Privacy Act Officer for instructions.
YES

NO

YES

NO

b. If no, contact the Privacy Act Officer for instructions.
3. Is the SSN Field needed?

YES

NO

a. If no, complete DD67 to request revision of the form.
4. Could an alternative to the SSN be used?

YES

2. Does the form contain a Privacy Act Statement (PAS)?
a. If yes, has the PAS been approved by a Privacy Act Officer?

NO

a. If yes, complete DD67 to request revision of the form.
YES

NO

a. If yes, is the SSN field masked or truncated?

YES

NO

b. If no, could it be?

YES

NO

YES

NO

YES

NO

YES

NO

5. Is this form electronic?

6. Is this form part of an IT system?
a. If yes, what is the IT System name and DITPR DON ID?
b. If yes, does the IT System mask or truncate the display of the SSN on the form?
c. If no, Could it be?

YES

7. Is Justification Memorandum for the Record attached?

NO

CONTACT INFORMATION - IT System Owner or Form Originator/Sponsor
Name, Code, Mailing Address

LCDR Martin Fajardo, 52 King George St. Annapolis, MD 21402

Office Telephone Number:

(410)-293-1825
E-mail Address

mfajardo@usna.edu

SECTION 2 TO BE COMPLETED BY PRIVACY ACT OFFICER

To verify information given in Section 1 is accurate, is in compliance with Privacy Act Regulations, and meets requirements of the
SSN Reduction Plan.
1. Is Privacy Act Statement (PAS) correct?

YES

NO

2. If there is not a PAS, is one needed?

YES

NO

3. If a PAS needed, what is the correct PAS? (Originator/owner of form/IT system will work with the Privacy Act Officer to draft a PAS if needed) (Field will expand
to fit typed data))

Authority: 10 U.S.C. 6958, Midshipmen: Qualifications for Admission; DoDI 1322.22, Service Academies; and E.O. 9397 (SSN),
as amended, and N01531-1.
Purpose: Candidates receiving an offer of appointment are required to obtain a routine Police Record Check from their local police
department. This background check is a precursor to the National Agency Check (NAC) that will be initiated on Induction Day at the
Naval Academy.
Routine Uses: Information will only be collected and accessed by the Office of Admissions of the United States Naval Academy for
the purposes of admissions and enrollment.
Disclosure: Voluntary; however, failure to provide the required information may result in a delay or inability to process the
applicant’s application.
4. Is the System of Records Notice (SORN) number cited in Section 1 correct?

YES

NO

5. Does a SORN need to be initiated?

YES

NO

(Determination of need for SORN will be worked between the originator/owner of form/IT system and Command Privacy Act Office)

SECNAV 5213/1 (REV 10/2016)

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SECNAV RCS 5213/1 (Effective 11/1/2016 through 11/31/2019)
GENADMIN DON CIO WASHINGTON DC 192101Z REV 10/2016
YES

6. Is use of SSN Justification Form complete and approved?
APPROVED
DISAPPROVED

Privacy Act Officer Printed Name

CAMPBELL.SHANNON.CARA.1 Digitally signed by
CAMPBELL.SHANNON.CARA.1268432309
268432309
Date: 2018.10.25 15:43:35 -04'00'
Privacy Act Officer Signature

NO

25 Oct 2018
Date

SECTION 3 - COMMAND FORMS MANAGER
APPROVED
DISAPPROVED
NOTES:

Forms Manager Printed Name

CAMPBELL.SHANNON.CARA. Digitally signed by
CAMPBELL.SHANNON.CARA.1268432309
1268432309
Date: 2018.10.25 15:44:00 -04'00'
Forms Manager Approval Signature

25 Oct 2018
Date:

(1) For IT systems / applications, this completed SECNAV 5213/1 will be posted in the DOC tab of DITPR DON / DADMS respectively.
(2) For forms, post the date this SECNAV 5213/1 is approved in Naval Forms Online https://navalforms.documentservices.dla.mil/web/public/home.
and maintain the SECNAV 5213/1 in the form's history/case file.
(3) Approved share drive / web portal forms will be maintained locally by the share drive / web portal owner.

SECNAV 5213/1 (REV 10/2016)

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SECNAV RCS 5213/1 (Effective 11/1/2016 through 11/31/2019)
GENADMIN DON CIO WASHINGTON DC 192101Z REV 10/2016

SSN USE REVIEW AND JUSTIFICATION FOR FORMS

26 Sep 2018
Date

MEMORANDUM FOR THE RECORD
Subj: JUSTIFICATION FOR THE USE OF THE SOCIAL SECURITY NUMBER (SSN)
1. What is the purpose of this form?

Candidates receiving an offer of appointment are required to obtain a routine Police Record Check from
their local police department. This background check is a precursor to the National Agency Check (NAC)
that will be initiated on Induction Day at the Naval Academy. The Police Record Check and the NAC are
utilized to determine credibility and suitability for service and to grant a security clearance for access to
classified material.

2. Why is collection of the SSN necessary?

There is not another unique identifier available that can be used to verify information across schools
throughout the world and among law enforcement agencies.
If eliminated, confirming applicants' data will be more difficult and labor intensive. Law enforcement officials
would need to expend more time and effort to verify data for a particular individual which would delay the
data verification for USNA Office of Admission's staff. This would require more time per record for
processing. There is also a reasonable expectation for an increase in having the wrong information added
to applicant records with duplicate names resulting in more man hours spent resolving mistakes. The
quality of customer service and capacity of record production for getting completed records to the
Admissions board would both decrease as more man hours would be spent resolving student-to-data
correlation issues.
3. List the acceptable use criteria for the SSN (found at this link: http://www.doncio.navy.mil/ContentView.aspx?ID=1833)

Law Enforcement, National Security and Credentialing: Almost every law enforcement application must be
able to report and track individuals through the use of the SSN. This includes, but is not limited to, checks
of the National Crime Information Center, state criminal histories and Federal Bureau of Investigation
records checks.
Security Clearance Investigation or Verification: The initiation, conduct or verification of security clearances
requires the use of the SSN. The SSN is the single identifier that links all the aspects of these
investigations. This use case is also linked to other Federal agencies that continue to use the SSN as a
primary identifier.
4. If collection of the SSN is no longer necessary and a unique identifier can be substituted for the SSN or the SSN can be eliminated,
on what date will either the substitution or elimination occur?

N/A

LANG.GEORGE.EDWAR
D.JR.1018678698

Digitally signed by
LANG.GEORGE.EDWARD.JR.1018678698
Date: 2018.10.25 16:22:08 -04'00'

Commanding Officer

SECNAV 5213/1 (REV 10/2016)

U.S. Naval Academy
Command/Activity

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