Annual Security Appraisal Form
FOR NATIONAL SECURITY CLEARANCE HOLDERS
The information collected in this form will be used by the organisation to manage your ongoing suitability for holding a national
security clearance. You must provide information on any:
changes in your personal, health, and financial circumstances
overseas travel private and work-related
contact with law enforcement officials
contact with foreigners that you have reported during the year.
The organisation sponsoring your clearance will hold the information you provide in confidence. They will use the information to
determine your ongoing suitability to hold a clearance and may also use the information in this form to address any issue they assess
to be a security risk.
This form is sent to you on the anniversary date of your clearance or at a date your organisation chooses.
This section to be completed by security team or chief security officer prior to sending out.
Reference number:
Date:
Reporting Period:
Expiry Date:
Your personal details
First name
Family name
Job title
Details of organisations that sponsored or shared your clearance
Organisation who sponsors your clearance
Line manager at sponsoring organisation
Has your clearance been shared with any other
organisations during the reporting period?
Yes No
If yes, which organisation(s)?
Line manager(s) at the organisation(s)
Security clearance level(s)
Confidential
[ Insert classification here ]
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dd/MM/yyyy
dd/MM/yyyy
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[ Insert classification here ]
Confidential
Work roles
Please list your roles, clearance levels, and line managers you have worked for during the reporting period.
Role
Clearance level
Start date
End date
Line manager
Personal changes
In the past 12 months, have you had any of the following things happen? Yes No
If Yes, tick all the boxes that apply and provide details below.
If No, go to the next section.
Were you...
deliberately involved in any criminal activity?
unintentionally involved in any criminal activity?
associated with any criminal groups?
a victim of crime?
involved in an accidental or one-off security breach
or incident?
subject to any disciplinary procedures?
Did you experience any...
changes in your mental health and wellbeing?
major medical events?
significant changes in your financial circumstances (eg,
windfalls, losses, increases in debt, bankruptcy)
changes in your close personal relationships?
addictive behaviours (eg, drugs, alcohol, gambling)
Did you change your...
name?
address?
living arrangements (eg, new flatmates or housemates,
Airbnb guests, boarders, or whānau members)?
residency status or citizenship?
Did you...
live in or visit any foreign countries?
have any relatives living in countries outside the Five Eyes
countries (Australia, Canada, New Zealand, United
Kingdom, United States)?
have any non-routine communications with employees of
any foreign government?
get an emergency clearance upgrade?
have any other changes? (Please specify below.)
Role
Role
Role
Role
Role
Name
Name
Name
Name
Name
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
[ Insert classification here ]
[ Insert classification here ]
Confidential
Confidential
Confidential
Confidential
Confidential
Give details of changes in your personal circumstances
Had you previously reported this change? Yes No
Who did you report it to?
Further details from your past 12 months
1.
In the past 12 months, have you accessed classified information?
(CONFIDENTIAL, SECRET, or TOP SECRET)
Yes
No
What was the highest classification of information you accessed?
How often did you access classified information?
2.
In the past 12 months, have you had official or social contact that appeared
suspicious, ongoing, unusual, or persistent?
Yes Give details below.
No Go to question 3.
If you answered Yes, please outline details of who initiated the contact, including their names if you know them:
- When and where you were contacted
- Who were they?
- How did they contact you?
- Overview of situation
[ Insert classification here ]
[ Insert classification here ]
Details of change
Reporting details
Reporting details
Confidential
3.
In the past 12 months, has anyone in organisations you’ve worked for asked
you for access to classified information, assets, or work locations, that they
don’t know about?
Yes Give details below.
No Go to question 5.
If you answered Yes, please outline details of who initiated the contact, including their names if you know them.
4.
If you answered Yes to question 3, did you report this access request
at the time?
Yes
No
5.
Do you have any security concerns about yourself, your organisation, or any
other clearance holders you would like to discuss?
Yes
No
If you selected ‘Yes’ to question 5, please provide details below. If you would
like to speak with the security team or chief security officer, please select the
checkbox below:
Request to speak with the security team or chief security officer.
Once you have completed this form, email a copy of this form to [enter details of form here].
[ Insert classification here ]
[ Insert classification here ]
Access requests
Security concerns
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