Reference number
Date
Annual Security Appraisal Form
For security teams or chief security officer
Security assessment for
Reporting period
Has the clearance holder indicated any change to their circumstances?
Yes No
Has your security team identified any national security risks?
Yes No
Should the clearance holder continue to have their current access?
(To information, assets, and work locations)
Yes No
Assessment of clearance holder’s ongoing suitability
Outline any concern, intended management plan, security awareess training needed,
or further security briefing required for this clearance holder.
For more guidance on assesing and acting on a clearance holder’s change in circumstances, go to:
https://protectivesecurity.govt.nz/assets/Personnel-security/PERSEC-ChangeofCircumstance-v4.pdf
If your security team or chief security officer is unsure whether anything in the annual security appraisal forms will impact the clearance
holders suitability to continue to hold the clearance, contact: psr@protectivesecurity.govt.nz
Result
Routine nothing of concern identified
Concerns contact the clearance holder
Clearance holder has requested contact
This following is to be completed by security
team or chief secrity officer prior to sending out.
[ Insert classification here ]
dd/mm/yyyy
dd/mm/yyyy
Enter name of national security clearance holder
dd/mm/yyyy
Assessment details
[ Insert classification here ]
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