Fillable 20180515-Security Appraisal Form V1.1 - 20100928_Security Appraisal Form_U

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20180515-Security Appraisal Form V1.1 - 20100928_Security Appraisal Form_U

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OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
1
OFFICIAL-SENSITIVE (WHEN COMPLETED)
HM Government
Security Appraisal Form
For official use only: Date of issue Case ID
Part A – Individual’s Annual Security Appraisal Form
As the clearance holder, you must complete:
• PART A of this form
• The ‘Subject Details’ at the start of PART B.
You must then:
• Send PART A by post to your vetting service provider
• Pass PART B to your Line Manager/Supervisor/Security Controller
for them to fill in the remaining fields. If you have worked for them
for less than 12 months, please ensure that they have the
opportunity to speak to your previous Line Manager /Supervisor/
Security Controller
If completing the form by hand, please write in BLACK INK using BLOCK
LETTERS
SUBJECT DETAILS
a. Reference number (if applicable)
(if you received an email asking you to complete this form, it will include a
reference number)
b. Surname/family name:
c. Forename(s):
d. Date of birth
Day Month Year
e. Staff/service number (or Company details if a Contractor):
Form NSV006 (09/2016)
You should be aware that failure to complete
this form and return it to your local security
unit/controller (or direct to the relevant
vetting provider) within the specified
deadlines could result in withdrawal of your
security clearance.
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
2
OFFICIAL-SENSITIVE (WHEN COMPLETED
)
f. Current Work Address:
Name of Organisation:
Type of address: UK Overseas BFPO
Please fill in the fields which are applicable:
Building number: Building name:
(BFPO addresses only)
Name/Rank/Number:
BFPO Code:
Address Line 1:
Address Line 2:
Address Line 3:
Town:
County (or Region/Area/State
for overseas addresses):
Postcode (or equivalent, where applicable,
for overseas addresses):
Country (if not UK or a BFPO address):
g. Telephone number:
h. Clearance currently held:
i. Period of security appraisal:
From: To:
Mon
th Year Month
Year
Completing an annual security appraisal is a requirement in order to retain your
security clearance. The process provides assurance to yourself, your line
manager/ supervisor/security controller and the organisation in which you are
based that your actions and behaviours are consistent with the level of access
entrusted to you.
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
Once your completed Security Appraisal Form has been received your records
will be updated. Security teams/controllers or vetting officers may need to
make follow-up enquiries concerning information that you provide, particularly
where your personal circumstances have changed
Please contact the vetting authority or your Departmental or Site Security
Officer if you have any questions relating to any aspect of this form or the
annual security appraisal process.
A data processing privacy notice explaining how your data is stored and
handled in the course of national security vetting is available online at
https://www.gov.uk/government/publications/national-security-vetting-privacy-
notice
1.
Have your personal circumstances changed within
this appraisal period? (Such as (a) getting married,
entering a Civil Partnership or starting to live with a
partner as a couple, (b) change of forename or
surname, (c) criminal conviction, arrest or caution, (d)
changed, new or revoked nationality, including
naturalisation, (e) a substantial change in financial
circumstances, both loss and gain, (f) begun living
with a new co-resident in shared accommodation (DV
holders only).)
If you answered ‘Yes’, have you completed and
submitted a Change of Personal Circumstances
form to report these changes?
Yes No
Yes No
• IMPORTANT - It is your personal responsibility to
complete a Change of Personal Circumstances
(CPC) form as soon as any of these events occur.
• Failure to do so can result in your clearance
being withdrawn.
• If you have not already done so, you must now
complete and submit a CPC form to inform us of
your change of circumstances.
If you answer ‘Yes’ to any of the following questions in Section 2, 3 or 4,
please give details on the continuation sheet (Page 6), quoting the
question number.
3
OFFICIAL-SENSITIVE (WHEN COMPLETED)
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
4
OFFICIAL-SENSITIVE (WHEN COMPLETED
)
2. Personal Concerns
3. Personal Associations
b. Has the amount of alcohol you regularly consume
increased?
d. Have you experienced an alcohol-related illness or has
your performance at work been affected by your
consumption of alcohol?
e. Have you taken illegal drugs or had any issue with
prescription medication in the last 12 months?
f. Have you sought medical advice or received treatment
for alcohol or drug use/addiction in the last 12 months?
a. Have you associated with any political or religious
group that has views which conflict with your department’s
or organisation’s values, goals or policies (includes any
conversations or contact either in person, by phone,
through social media or any other route)?
b. Do you or any of your close family or friends have
associations (including overseas connections) with
individuals, organisations that could cause concern or be
used to place pressure upon you as an individual?
a. During this appraisal period have you experienced, or
are you currently experiencing, any serious personal
difficulties? (For example, ill health, legal troubles,
domestic/marital problems.)
c. Please estimate the number of units of alcohol that
you regularly consume in a week:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
5
OFFICIAL-SENSITIVE (WHEN COMPLETED
)
4. Employment Concerns
If you have answered yes to any of the questions in sections 2-4, please
give details below. Continue on the next page if necessary.
c. Have you conducted any activity or formed any
connections online/through social media etc. that could be
exploited or used to apply pressure on you?
d. Have you publically discussed details about your role
and/or security clearance which could make you vulnerable
to being targeted by an external actor? (e.g. through social
media or personal profiles)
e. Have you engaged in any activity via social media or
internet sites that could be used to embarrass or place
pressure on you (e.g. exchange of explicit images)?
a. Do you have any reservations, moral or otherwise, about
any aspect of your work or the wider activities of your
employer/ government organisation?
b. Have you been the subject of any disciplinary action,
complaint or grievance in this period?
c. Have you committed any security breaches during this
appraisal period?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
6
OFFICIAL-SENSITIVE (WHEN COMPLETED
)
Continuation sheet (for use by the clearance holder):
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
7
OFFICIAL-SENSITIVE (WHEN COMPLETED
)
5. Please provide details of your current Line Manager, Supervisor or
Security Controller, to whom you will be passing Part B of this form.
Surname/family name: Title/rank:
Forename(s): Post title:
Current address:
Name of Organisation:
Type of address: UK Overseas BFPO
Please fill in the fields which are applicable:
Building number: Building name:
(BFPO addresses only)
Name/Rank/Number:
BFPO Code:
Address Line 1:
Address Line 2:
Address Line 3:
Town:
County (or Region/Area/State
for overseas addresses):
Postcode (or equivalent, where applicable,
for overseas addresses):
Country (if not UK or a BFPO address):
Telephone number:
Email:
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
8
OFFICIAL-SENSITIVE (WHEN COMPLETED
)
STATEMENT
I understand my obligation to inform the Departmental, Site Security Officer,
Security Controller or vetting provider (as required by the policy in my area)
of any material changes in my circumstances.
I have today passed Part B of this form to the appropriate line
manager/supervisor.
Signature: ……………………………….. Date:
PLEASE RETURN PART A TO BY POST TO YOUR VETTING PROVIDER
AND ASK YOUR LINE MANAGER, SUPERVISOR OR SECURITY
CONTROLLER TO COMPLETE PART B.
Information contained in this document may be subject to exemption under
the Freedom of Information Act (in particular the National Security exemptions
in sections 23 and 24). Before considering information in this document for
release under the Act, you should contact the National Security Secretariat in
the Cabinet Office for advice.
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
9
OFFICIAL-SENSITIVE (WHEN COMPLETED)
Part B – Line Manager’s assessment of the Annual
Security Appraisal Form
This section is to be completed by the clearance holder:
SUBJECT DETAILS (the person who is being reported on):
a. Reference number (if applicable)
(if you received an email asking you to complete this form, it will include a
reference number)
b. Surname/family name:
c. Forename(s):
d. Date of birth
Day Month Year
e. Staff/service number (or Company details if a Contractor):
f. Current work address:
Name of Organisation:
Type of address: UK Overseas BFPO
Please fill in the fields which are applicable:
Building number: Building name:
(BFPO addresses only)
Name/Rank/Number:
BFPO Code:
Address Line 1:
Address Line 2:
Address Line 3:
Town:
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
10
OFFICIAL-SENSITIVE (WHEN COMPLETED)
County (or Region/Area/State
for overseas addresses):
Postcode (or equivalent, where applicable,
for overseas addresses):
Country (if not UK or a BFPO address):
g. Telephone number:
h. Clearance currently held:
i. Period of security appraisal:
From: To:
Mon
th Year Month Year
The rest of the form is to be completed by the clearance holder’s line
manager or supervising officer
•
The annual Security appraisal of the vetting subject named above is now
due and you are understood to be the Supervising Officer for that
individual.
• Line Managers/Supervising Officers are required to complete an annual
security appraisal for individuals in DV posts (or those with Enhanced SC
clearance). Appraisals should provide an honest, accurate assessment
of the subject’s character, conduct and reliability.
• If you do not consider yourself suitable to assess the individual
who has passed you this form it is your responsibility to identify
who is and to ensure they complete the following
• If completing by hand, please write in BLACK INK using BLOCK
LETTERS
• After you have completed this form, please return it by post to the
vetting provider.
Date on which you received the form from the clearance holder:
Day Month Year
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
11
OFFICIAL-SENSITIVE (WHEN COMPLETED)
Your details:
Your surname/family name:
Your forename(s):
Current Work Address:
Name of Organisation:
Type of address: UK Overseas BFPO
Please fill in the fields which are applicable:
Building number: Building name:
(BFPO addresses only)
Name/Rank/Number:
BFPO Code:
Address Line 1:
Address Line 2:
Address Line 3:
Town:
County (or Region/Area/State
for overseas addresses)
Postcode (or equivalent, where applicable,
for overseas addresses):
Country (if not UK or a BFPO address):
Telephone number:
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
12
OFFICIAL-SENSITIVE (WHEN COMPLETED)
1. Contact with the Subject
a. For what period has the Subject been under your supervision?
From: To:
Month Year Month Year
b. How much contact do you have with the Subject at work?
Daily Weekly Less frequently than weekly
2. Personal Qualities
Do you have any concerns regarding the Subject’s :
Yes No
Yes No
If you have answered ‘Yes’ to either of these questions, please give details
below. Use the continuation sheet (Page 1
8 ) if necessary.
d. Do you have any reservations about supervising
the Subject/accounting for their reliability in this
context? (You should highlight any concerns,
however small they may seem.) If so, please give
details. Use the continuation sheet (Page 1
8) if
necessary.
a. Approach and commitment to their job or work
performance over the appraisal period?
b. Security Awareness (e.g. their attitude towards
personal, physical and IT security procedures). Please
note any security breaches or poor security behaviour
that have occurred during the period involving the
individual.
c. Have you supervised the individual for the full
12 month appraisal period?
Yes
No
Yes
No
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
13
OFFICIAL-SENSITIVE (WHEN COMPLETED)
3. Behaviour
To the best of your knowledge, has the Subject shown any evidence of:
Misuse of drugs? Yes No
Misuse of alcohol? Yes No
Unreliability/dishonesty/untrustworthiness/indiscretion? Yes No
Significant financial difficulties or unexplained affluence? Yes No
Conduct liable to lead to vulnerability to blackmail? Yes No
Yes No
If you have answered ‘Yes’ to any of these questions, please give details
below. Use the continuation sheet on the next page if necessary.
4. Other Information
Are you aware of any other grounds that might cast doubt upon the Subject’s
continued suitability for security clearance? If so, please give details below. If
necessary please use the continuation sheet on the next page.
Views or actions conflicting with your
organisation’s values or (where
applicable) the Civil Service Code?
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
14
OFFICIAL-SENSITIVE (WHEN COMPLETED)
Continuation sheet (for use by the line manager):
OFFICIAL-SENSITIVE (WHEN COMPLETED
Handling Instruction: Vetting-in-Confidence
15
OFFICIAL-SENSITIVE (WHEN COMPLETED)
Please sign and date the form, and return it by post to the vetting service
provider.
Signature: ……………………………….. Date:
Information contained in this document may be subject to exemption under the
Freedom of Information Act (in particular the National Security exemptions in
sections 23 and 24). Before considering information in this document for release
under the Act, you should contact the National Security Secretariat in the
Cabinet Office for advice.
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