Department of Veterans Affairs
VHA Service Center Personnel Security
6100 Oak Tree Blvd #500
Independence, OH 44131
CONTRACT SECURITY SERVICES REQUEST - INSTRUCTIONAL FORM 1A
Purpose: The Contract Security Services Request is submitted to VSC to initiate the contract security verification process. By submitting this form, our
office will ensure that each individual listed have been fingerprinted, the fingerprints are adjudicated if necessary, background investigations are
initiated or existing background investigations are current and PIV badges are managed and sponsored. This form should be completed and signed by
the contracting officer. Please refer to the instructions below when completing the Contract Security Services Request Form #1.
A Contracting Officer & Phone: Please provide the post-award contracting officer handling this contract and their phone number.
B COR (COTR) Name & Phone: Please list the Contracting Officer Representative (previously the Contracting Officer Technical
Representative) and phone number. The COR is the liaison between the contracting officer and contracted company.
C Contract End Date: Please list the date in which the contract ends including all options to extend (for PIV badge expiration).
D SAO Region: Please list the Service Area Office in which the contracting officer is associated with (East, West or Central).
E Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station.
Should the task order number change at fiscal year end, please indicate on any future requests by listing the old task order number in
parenthesis next to the new task number.
F Contractor Position Description: Please provide a position title for all individuals (ex: physician, consultant, electrician).
G Investigation Level: Please indicate the background security requirements as provided by the PDAT (Position Description
Automated Tool). This would include background screening (SAC), low-level investigation (NACI), moderate-level investigation (MBI)
and high-level investigation (BI). Please note that non-PIV badges (contract under 180-days) require at minimum a SAC, full PIV
badges (over 180-days) require at minimum a NACI.
H Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task
order. Please provide subcontractors in parenthesis.
I Contractor Address: Please provide the contracting company address. This information is required for the Little Rock SIC
investigation request.
J Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information.
This person may be contacted to provide additional information or documents in the process. All communication with this individual
will include the contracting officer and COTR.
K Contractor POC Email: Please provide the email address for the above mentioned point-of-contact. This email will be included in
the investigation request submitted to Little Rock SIC.
L Contracting Officer Signature: All requests must be signed by the contracting officer/specialist. This signature verifies that an
official contract is in place prior to processing the applicants for investigation and badging.
M Station Number: Please indicate the facility station number where the work is being performed/facility to be billed.
N Network Access: Please indicate whether the individuals will be obtaining network access.
O Employee Name: Please provide the full legal name of the individuals working on this task order.
P SSN: Please provide complete social security numbers for all individuals listed.
Q Email Address: Please provide a valid email address for all individuals.
R DOB: Please provide date of birth for all individuals listed.
S Place of Birth: Please provide place of birth for all individuals listed, including city, state and country (if outside US). For foreign-
born individuals, please provide proof of citizenship.
