Form INV 41 INV 41 Investigative Request for Employment Data

t

|

|

|

|

INV FORM 41 (Rev. 10/21)
DEFENSE COUNTERINTELLIGENCE
AND SECURITY AGENCY (EO 13467)
F
R
O
M

INVESTIGATIVE REQUEST FOR EMPLOYMENT
DATA AND SUPERVISOR INFORMATION
U.S. GOVERNMENT USE ONLY

DEFENSE COUNTERINTELLIGENCE AND SECURITY AGENCY
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
BOYERS, PA 16018-0618

T
O

PRIVACY ACT STATEMENT: The information you provide, including your identity, will be furnished to the agency requesting the investigation, other agencies as warranted, and
to the person investigated upon his or her specific request. AUTHORITY: Section 925 of Public Law 115-91; 5 USC 301; Executive Order 13467, as amended by Executive
Order 13869; and, 5 CFR 736. PRINCIPAL PURPOSE: To obtain background information and personal records for investigating and determining an individual’s initial or
continued: eligibility for access to classified national security information or assignment to positions with sensitive duties, suitability for enlistment or appointment into military
service, suitability for federal employment, fitness for assignment to work under contract for or on behalf of the government, or eligibility for physical or logical access to U.S.
Government systems or facilities. ROUTINE USES: The information collected may be disclosed to DCSA personnel and shared externally with other authorized government
agency personnel as a routine use when necessary and relevant to personnel vetting investigations, determinations, and adjudications; and, for other purposes permitted under
subsection (b) of the Privacy Act of 1974, as amended (5 USC §552a). Information obtained will also be released to the person being investigated upon their request unless
otherwise exempt. A complete list of the routine uses can be found in the system of records notice for the Department of Defense Personnel Vetting Records System, “DUSDI
02-DoD” at: https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records. DISCLOSURE: Disclosure is voluntary. However,
failure to provide DCSA access to the requested information may result in our agency’s inability to conduct a thorough investigation and may prevent the government from making
a determination or adjudication regarding the qualifications, suitability, eligibility or fitness of the person being investigated.
If you have significant information which you feel unable to furnish without a promise that your identity will be kept confidential, please indicate this in writing on the reverse side
of this form and provide only your contact information. Providing additional information on this form will void your request for confidentiality.
CERTIFICATION: The person we are investigating has given written consent for this investigative inquiry. We keep that consent on file. If a copy is required in order to complete
this form, please indicate this requirement in writing on the reverse.

Completion and return of this original form as soon as possible will help this person and the agency perform their duties
in a more timely and efficient manner.
CASE NUMBER:

CASE TYPE:

ITEM NUMBER:

FULL NAME (LAST, FIRST, MIDDLE)
OTHER NAMES USED

DATE OF BIRTH

SOCIAL SECURITY NUMBER

POSITION REQUIRING INVESTIGATION

PLACE OF BIRTH
CLAIMED EMPLOYMENT
FROM

TO

POSITION

NAME OF SUPERVISOR

ACTUAL JOB LOCATION (IF DIFFERENT THAN ABOVE ADDRESS)

PUBLIC BURDEN STATEMENT: The public reporting burden for this collection of information, OMB 0705-0003, is estimated to average 5 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services,
at whs.mc-alex.esd.mbx.dd-dod-infor-mation-collections@mail.mil. 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.

U.S. GOVERNMENT PUBLISHING OFFICE

221431-9

EXPIRATION DATE: 10/31/24

FORM APPROVED: OMB:0705-0003
C
C

t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t

INSTRUCTIONS: Your contact information was provided by the person identified below to assist in completing a background investigation to help
us determine this person’s eligibility for employment or security clearance. To help us make this determination, we ask that you complete all items
on the back of this form and return the form in the enclosed envelope.

|

MARKING
INSTRUCTIONS
CORRECT MARK:

\

»
\

|

• USE A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY.
• DO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER.
• DO NOT MAKE ANY STRAY MARKS ON THIS SHEET.

\

|

|

INCORRECT MARKS:

\

\

\

\

PLEASE COMPLETE THE ITEMS SHOWN BELOW
1

IS THE INFORMATION ON THE FRONT OF THIS FORM THE SAME AS SHOWN IN YOUR RECORDS?

a
2

3

\
» NO (Please explain in item 6)

c

\
» WE HAVE NO RECORD ON THIS PERSON

d

RECORD AT ANOTHER LOCATION

\
» (Enter address and ZIP Code in #6)

MARK ONE OF THE FOLLOWING PERTAINING TO THIS PERSON’S EMPLOYMENT:

\
» SUBJECT CURRENTLY EMPLOYED HERE

e

\
» FIRED (Please explain in item 6)

b

\
» LEFT EMPLOYMENT VOLUNTARILY/EMPLOYMENT

f

\
» QUIT AFTER BEING TOLD THEY WOULD BE FIRED

c

\
» SEPARATED BECAUSE OF COMPANY CUTBACK IN

g

\
» LEFT BY MUTUAL AGREEMENT FOLLOWING CHARGES OR

d

\
» LEFT EMPLOYMENT VOLUNTARILY/EMPLOYMENT NOT

h

\
» LEFT BY MUTUAL AGREEMENT FOLLOWING NOTICE OF

ENTIRELY FAVORABLE

WORKFORCE OR CHANGE IN SKILL NEEDS

ENTIRELY FAVORABLE (Please explain in item 6)

(Please explain in item 6)

ALLEGATIONS OF MISCONDUCT (Please explain in item 6)

UNSATISFACTORY PERFORMANCE (Please explain in item 6)

IS THIS PERSON ELIGIBLE FOR REHIRE?

\
» YES

b

\
»

c

NO - DUE TO COMPANY POLICY AND/OR
NOT RELATED TO UNFAVORABLE EMPLOYMENT

\
»

NO - FOR REASONS RELATING TO UNFAVORABLE
EMPLOYMENT (Please explain in item 6)

DO YOU HAVE ANY REASON TO QUESTION THIS PERSON’S HONESTY OR TRUSTWORTHINESS?

a
b
5

b

a

a
4

\
» YES

\
» NO
\
» YES (Please explain in item 6)

c
d

\
» I DO NOT KNOW THIS PERSON WELL ENOUGH TO RESPOND
\
» I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

DO YOU HAVE ANY ADVERSE INFORMATION ABOUT THIS PERSON’S EMPLOYMENT, RESIDENCE OR ACTIVITIES CONCERNING:
YES NO

a
b
c

YES NO

\
»\
» VIOLATIONS OF THE LAW
\
»\
» FINANCES
\
»\
» ABUSE OF ALCOHOL

d
e

YES NO

\
»»
\ ABUSE/ILLEGAL USE OF DRUGS
\
»»
\ MENTAL OR EMOTIONAL STABILITY

»
\»
\ GENERAL BEHAVIOR OR CONDUCT
g »
\»
\ OTHER MATTERS
f

(If YES to any of these questions, please explain in item 6)

\
»

I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

6

\
»

7

IF ADDITIONAL INFORMATION IS PROVIDED BELOW, YOU MUST FILL IN THIS MARK

ADDITIONAL INFORMATION WHICH YOU FEEL MAY HAVE A BEARING ON THIS PERSON’S ELIGIBILITY FOR EMPLOYMENT
OR SECURITY CLEARANCE. THIS SPACE MAY BE USED TO PROVIDE DEROGATORY AS WELL AS POSITIVE INFORMATION,
TO REQUEST CONFIDENTIALITY, AND/OR TO REQUEST A COPY OF THE CONSENT.

DO YOU RECOMMEND THIS PERSON FOR ELIGIBILITY FOR EMPLOYMENT OR SECURITY CLEARANCE?

a
b

»
\ YES
»
\ NO (Please explain in item 6)

c

»
\ I DON’T KNOW THIS PERSON WELL ENOUGH TO MAKE A RECOMMENDATION

PRINT NAME:
DATE

SIGNATURE:
YOUR TITLE/ORGANIZATION:

DAYTIME TELEPHONE NUMBER
(INCLUDE AREA
CODE)

(

)

FOR DCSA USE ONLY
ISSUES/CHARACTERIZATION

RESULTS
AC ACCEPTABLE
\
AA
\ ACCEPTABLE/ATTACHED
PA CONFIDENTIAL/ACCEPTABLE
\
NI NO PERTINENT INFORMATION
\
NR
\ NO RECORD
NL NOT LOCATED
\
UC
\ UNABLE TO CONTACT
RF REFERRED
\
RR
\ RECORD

IS ISSUES
\
PI CONFIDENTIAL/ISSUES
\
RI
\ RECORD INCONCLUSIVE
FR FEE REQUIRED
\
RL RELEASE REQUIRED
\
SK
\ SUBJECT UNKNOWN
NZ NOT AVAILABLE
\
DN
\ DISCREPANT

1
2
3
4
5
6
7
8

\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N
\\\\\\\

O A B C D E N

O A B C D E N
9
\\\\\\\
O A B C D E N
10
\\\\\\\
O A B C D E N
11
\\\\\\\
O A B C D E N
12
\\\\\\\
O A B C D E N
13
\\\\\\\
O A B C D E N
14
\\\\\\\

T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T