tennessee valley authoritymulti.tva.gov/contractor/forms/tva/tva_personal_history... · tva 40932...

TVA 40932 (BLUE), INI / UPA / R1Y (12-31-2012) RESTRICTED INFORMATION Page 1 of 26

TENNESSEEVALLEYAUTHORITYNUCLEARPOWERGROUP

PERSONALHISTORYQUESTIONNAIRE(PHQ)

TVALOCATION: BrownsFerry Sequoyah WattsBar

Corporate Bellefonte

Name:

SSN:

Employer:

TodaysDate:

Ifyouhaveneverheldunescortedaccess,oryourlastaccesswasover3yearsago;orifyourlastunescortedaccesswas

deniedorterminatedunfavorably,checkhere: INITIAL

Ifyourlastunescortedaccessendedover365daysago,butlessthan3yrs,checkhere: UPDATE

Ifyourlastunescortedaccessendedover30daysago,butlessthan365days,checkhere: R1Y

**NOTE:Ifyourlastunescortedaccessendedlessthan31daysago,orifyoucurrentlyholdunescortedaccessatanothernuclearpowerplant,pleaseseePlantAccessfordifferentpaperwork.

Dateyoulastheldaccess:

Plantwhereyoulastheldaccess:

TVAUSEONLY: DATEFINGERPRINTSSUBMITTED:

PreHire TVA C/VDatehired:

CriticalGroup

YES NO

BIAgencysentto: DateSent:

ScannedtoAgency FaxedtoAgency

ScannedtoNAS FaxedtoNAS

TVA 40932 (BLUE), INI / UPA / R1Y (12-31-2012) RESTRICTED INFORMATION Page - 2 - of 26

AllinformationprovidedwillbetreatedasPERSONALCONFIDENTIALandobservedonlybypersonswithanauthorizedNEEDTOKNOW,orinaccordancewithapplicablelaw.

InordertomeettherequirementsoftheNuclearRegulatoryCommission(NRC)theTennesseeValleyAuthorityNuclearPowerGroup(TVANPG),towhichyouareapplyingforunescortedaccessauthorization(UAA),unescortedaccess(UA)and/oraccesstosafeguardsinformationrequiresthatyouconsenttoundergoabackgroundscreeningprocess.Thepurposeofthescreeningprocessistodetermineyourtrustworthinessandreliabilitytoworkwithintheprotectedandvitalareasofanuclearpowerplant(NPP).InformationfromthisformwillbeusedtoconductabackgroundinvestigationforaccessauthorizationpurposesasrequiredbytheNRC.Youmustprovideallinformationrequestedinacompleteandaccuratemanner.Yoursignatureonthedocumentisyourcertificationthattheinformationyouhaveprovidediscompleteandcorrect.ProvidingdeliberateorwillfulmisleadingstatementstoanyNPPwiththeintenttogainaccessisaviolationofFederalregulations.Anymisrepresentation,deliberatemisstatement,falsificationorwillfulomissionmayconstitutecausefordenialorrevocationofUAA/UAand/oraccesstosafeguardsinformation.Failuretoreportandlistreasonsforanyprevioussuspension,revocationordenialofUAA/UAand/oraccesstosafeguardsinformationataNPPorotherentitysubjecttoeithertheNRCaccessauthorization,FFDorSafeguardsInformationregulationsmaybesufficientcausefordenialorrevocationofUAA/UAand/oraccesstosafeguardsinformation.IfsuchaninstanceisdetectedtheplantisrequiredtoadvisetheNRC.TheNRCmayinvestigateyouand,ifappropriate,criminalandcivilsanctionsmaybeimposedagainstyouifdeemedmaterialbytheNRC.Whensuchinstanceshavepreviouslyoccurred,theresulthasbeenalengthy(fiveyear)orpermanentexclusionfromworkatnuclearpowerplantsintheUnitedStates.

Thefactsconcerningyourcriminalhistoryorfitnessfordutyrecordmaybesubjecttointerpretationduetovaryingcategorizationsofsimilaroffensesbetweenstates.Itisthereforerequiredthatyoudiscloseallinformationthathasanypotentialforbeingconsideredasderogatorytominimizethelikelihoodofdiscrepanciesbetweentheinformationyouprovidedandthatobtainedfromothersources.AllinformationrequestedisneededforthepurposeestablishedbytheNRCregulationorOrders.ResultsoftheinvestigationwillbeavailableasspecifiedinyoursignedConsentform,toentitiesauthorizedbytheNRCpursuanttoUAA/UA,FFDandSafeguardsInformationregulations. InsomeofthesectionsofthePersonalHistoryQuestionnaire(PHQ)youarerequiredtoprovideyourpersonalinformation;inothersectionsyouwillberequiredtoacknowledgethatyouunderstandcertainongoingrequirementsorpersonalresponsibilities.Theinformationrequestedmayincludeanyorallofthefollowingtopics:verificationofidentify,selfdisclosuredata,employment/unemploymenthistory(includingmilitaryserviceand/oreducationinlieuofemployment),criminalhistory,credithistory,characterreferences,residences,andfitnessfordutyhistory.Whennotinuse,yourwritteninformationisstoredinasecureenvironment,whichmayincludebeingelectronicallyplacedinasecuredatabase,topreventunauthorizeddisclosureofpersonalinformation.

InformationfromthisformwillbeusedtoconductabackgroundinvestigationforaccessauthorizationpurposesasrequiredbytheNuclearRegulatoryCommission(NRC).Theinformationyouareaskedtoprovideisspecific,explicitpersonalhistoryinformationincluding:workhistoryandlocations,personalreferences,criminalhistory,andpsychologicalandfitnessfordutyhistory.Youmustprovideallinformationrequestedincompletingthisdocument.NoinformationisrequestedthatisnotneededforthepurposeestablishedbyregulationtoevaluateyourtrustworthinessandreliabilityforUAataNPP.

YOUAREREQUIREDTOREPORTANYLEGALACTIONSBETWEENSIGNINGTHISPHQANDBEINGGRANTED

UNESCORTEDACCESSAUTHORIZATION/UNESCORTEDACCESS.


Unlessotherwiseinstructed,youarerequiredtocompleteallportionsofthisPHQtobeconsideredforUAA/UAataTVAsite.Pleasetypeorprint(useblackink)thespecificanswerstoallquestionsandrequestsforinformation.Singlelineoutandinitialmistakes.Write"None"orN/Awhenthequestionisnotapplicable.Somequestionsarefollowedbyrequestsforadditionaldata.Enteralldatesintheformattwodigitmonth,twodigitdayandfourdigityear(MM/DD/YYYY).AttachadditionalpagestothePHQifthelengthofanexplanationexceedsthespaceprovided.Aftercompleting,reviewthequestionnairetoensuretherearenoomissionsandyourprintednameandsocialsecuritynumberareincludedoneachpage.WhenaskedYes/No,circleorchecktheapplicableresponse.

IhavereadandunderstandallinstructionsforcompletingthisPHQ ApplicantsSignature

HaveyoueverappliedfororbeengrantedUAA/UAataNPP? YesNoIfYes,lastUAA/UAwasterminatedFavorableorUnfavorable(CircleOne)at on:

PlantName DateHaveyoueverappliedfororbeengrantedaccesstoaNPPunderconstruction? YesNoIfYes,lastperiodofaccesswasterminated FavorableorUnfavorable(CircleOne)at on:

PlantName DateHaveyoueverappliedfororbeengrantedaccesstoSafeguardsInformationataNPPorNPPunderconstruction?YesNoIfYes,lastperiodofSafeguardsAccesswasterminated FavorableorUnfavorable(CircleOne)at on:

PlantName Date NRCESCALATEDENFORCEMENTACTIONNote:Occasionally,theNRCtakesenforcementactionagainstindividualsworkingundertheNRCsjurisdiction.WhentheNRClosesreasonableassurancethatanindividualiswillingorabletocomplywithNRCrequirements,typicallydemonstratedbydeliberatemisconduct,theagencymayissueanenforcementorderthatincludesaprohibitionagainstallorsomeformsofNRClicensedactivities.Inaddition,theNRCmayengageinalternativedisputeresolutionwithanindividualwhotheNRCbelieveshaswillfullyviolatedNRCrequirements.Throughalternativedisputeresolution,theNRCmayissueaconfirmatoryorderthatincludesanagreeduponperiodofprohibitionfromallorsometypesofNRClicensedactivities.Inlesssignificantcases,theagencymayissueanoticeofviolationtoanindividual. HaveyoueverbeenissuedanNRCEscalatedEnforcementAction? YesNo(CircleOne)Ifyes,pleaseprovidedetails.


SECTIONIPERSONALDATAProvidepersonalinformationinblanksprovided.Ensurethatthetelephonenumberyouprovideiscurrentintheeventyouneedtobecontactedforclarificationorforadditionalinformation,ifnecessary. Writelegiblyplease.

Name: , Last First Middle Sr,Jr,III

OtherNamesUsed: (Maiden,previousmarriages,aliases,nicknamesandwhenused.)

USSSN(SocialSecurity): BirthDate: / /

PermanentAddress: , , NumberandStreet City State Zip

TemporaryAddress: , , (Ifapplicable) NumberandStreet City State Zip

HomePhone: ( ) CellPhone: ( )

Daytime/LocalPhone: ( ) EMailAddress:

BirthPlace:City: State: Country: USA Other:

PERSONALDESCRIPTION:

EyeColor HairColor Height(ft./inch) Weight(lbs) Sex:M/F Race

AreyouaU.S.citizen? Yes No IfNo,whatisyourcountryofcitizenship?

IfyouwereNOTbornintheUnitedStates,providetheapplicableinformationspecifiedbelow:

DateandPortofEntryintoUS: / / , DateofEntry PortofEntry(City) (State)

Nameattimeofentry AlienRegistrationNumber NaturalizationNumber

/ / VisaType VisaNumber ExpirationDate

IfyoudonthaveaUSSSN,providealternatevalid(notexpired)governmentissuedidentification: IdentificationNumber/Type Source(e.g.,Passport)


SECTIONIPERSONALDATA(contd.)

U.S.DRIVERSLICENSEINFORMATION

Ifnovalidlicense,explain:

DriversLicenseNo.: State:

IssuedDate:/ / ExpirationDate: / /

UNIONINFORMATION: Craft: Home/Local#:

Phone:( ) City: State:

SECTIONIPERSONALDATARESIDENCESIfyouhaveNOTheldUnescortedAccessatanuclearplantwithinthelast3years,listallresidenceswhereyouhavelivedfor

morethan30daysinthepastseven(7)years.

IfyouHAVEheldUnescortedAccesswithinthelast3years,listallresidenceswhereyouhavelivedformorethan30dayssinceyoulastheldunescortedaccess.

From: / / To: Present

NumberandStreet City State Zip

From: / / To: / /


From: / / To: / /


From: / / To: / /


From: / / To: / /


From: / / To: / /


X ApplicantsFullPrintedName SocialSecurityNumber


SECTIONIPERSONALDATAFOREIGNTRAVELInthepast5years,sinceyour18thBIRTHDAY,orsinceyourlastfavorableaccesswhicheverperiodisshorter,haveyoutraveledtoanyforeigncountry?(CircleOne) Yes NoDonotincludetravelwhenintheserviceofanyUSgovernmentagency(e.g.,USMilitary,StateDepartment,etc.)CountryName:________________________________________________________DateDepartedUnitedStates:From:___/___/_____DateReturnedtoUnitedSates:To:___/___/_____PortofDeparture:______________________________________________________PurposeofTravel:______________________________________________________CountryName:________________________________________________________DateDepartedUnitedStates:From:___/___/_____DateReturnedtoUnitedSates:To:___/___/_____PortofDeparture:______________________________________________________PurposeofTravel:______________________________________________________CountryName:________________________________________________________DateDepartedUnitedStates:From:___/___/_____DateReturnedtoUnitedSates:To:___/___/_____PortofDeparture:______________________________________________________PurposeofTravel:______________________________________________________Useadditionalcontinuationsheets,asnecessary.SECTIONIIPERSONALREFERENCESList three individuals who are available for immediate contact and who can comment on your character and reputation. References cannot be related to you and cannot be living in your household. They may be friends, neighbors, or others with whom you have frequent personal and/or business relationships. Provide home address (actual street address), not post office box numbers. List telephone numbers where each reference can be reached.

Name Address PhoneNumbersincludingareacodes Daytime Evening

KnownSince

() ()

() ()

() ()

Closestrelativenotlivingwithyou:

Name: Relationship: PhoneNo:( ) NumberandStreet City State Zip



SECTIONIIICREDITHISTORY(NotapplicableifyouhaveheldUnescortedAccessatanuclearplantwithinthelast365days.)Inthepastseven(7)years,haveyouhad: Abankruptcy?............................................................................................. YES NO Afinancialjudgmentagainstyou?............................................................. YES NO Achargeoff?............................................................................................... YES NO Ataxlien?................................................................................................... YES NO Otherfinancialdifficultieswithinthepastseven(7)years?...................... YES NO

Ifyourespondedyestoanyoftheabove,providethereasonorcircumstancesforthesedifficulties:

Note:Ifyouhaveplacedasecurityfreezeonyourcreditfile,thecreditfilemustbeunfrozeninorderfortherequiredcreditchecktobecompleted.Changingthestatusofyourcreditfileisyourresponsibility.

Yourcreditwillbecheckedthroughanationalcreditagency.Ifyoudonothaveanestablishedcredithistory,listasourceofcreditsuchasabankordepartmentstorechargeaccountoranypersonalsourcesofcredit.(Examples:localgasstation,companysalesrepresentative,etc.)

Source: Location: , PhoneNumber:( ) Name City State

SECTIONIVEDUCATIONHISTORYASEMPLOYMENTInthepast5yearswereyouenrolled,witheducationasyourprimaryactivity,inaneducationalinstitutioninlieuofemployment? YES NOIf Yes, complete this section for each enrollment. Ifclaiminganyeducation,acopyofanofficialeducationalinstitutiontranscriptmustbeprovided.

NameofSchool Address(City/State)

DatesAttended(Mo/YrMo/Yr)

CourseofStudy

ReasonforLeaving

Wereyousubjecttoanydisciplinaryactionatanyoftheabovelistededucationalinstitutes? YES NO

Ifyes,providedetails:

SECTIONVMILITARYSERVICEASEMPLOYMENT

Didyouserveinthemilitaryasprimaryjobwithinthelastthree(3)yearsorsinceyour18thbirthday? YES NOIfYescompletethissectionforeachperiodofservice. DoyouhavetheDDForm214youreceivedupondischarge? YES NOIfYes,presenttheOriginalDD214withthisPHQ,acopywillberetainedandtheoriginalreturnedafterauthentication.

DateofService:From: / / To: / /

BranchofService: TypeofService: ActiveDuty NationalGuard/Reservesonactiveduty

LastCommander: LastDutyStation: PhoneNo:( )

ReasonforDischarge:

CharacterofService: Honorable Other,explain:

AnyDisciplinaryaction: YES NO Ifyes,explain:



SECTIONVIEMPLOYMENTHISTORYIfyouhaveNOTheldUnescortedAccessatanuclearplantwithinthelast3years,listallemployment/unemploymentforlast5years.IfyouHAVEheldUnescortedAccesswithinthelast3years,listallemployment/unemploymentsincelastaccess.Donotleavegaps.Donotlistunemploymentofficeorlocaluniontoverifyemploymentorunemployment.Haveyoubeenfired,involuntarilyterminated,orforcedtoleaveanyjoborposition,exceptaspartofareductioninforce,withinthepastfive(5)years? YES NOIfYes,explainthecircumstancesandreasonforleavingatbottomofpage12.

Unemployed:From:To:

Nameofpersonwhocanverify:DaytimePhoneNo: Evening:

EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:

/ /Employed/SelfEmployedTo:

/ /HomeOfficeAddress: PositionHeld: PhoneNo:

()

JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit

EligibleforRehire*: Yes No

If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:

Name:PhoneNo:()Unemployed:From:To:





()









()JobSiteLocation:(City/State) ReasonforTermination*:

Fired LaidOff QuitEligibleforRehire*: Yes No




*Iffiredornoteligibleforrehire,provideexplanationatbottomofpage12.



EMPLOYMENTHISTORY(continued)Donotleavegaps.Donotlistunemploymentofficeorlocaluniontoverifyemploymentorunemployment.




()









()









()









()




Name:PhoneNo:()*Iffiredornoteligibleforrehire,provideexplanationatbottomofpage12.




Unemployed:From:To:





()









()









()









()







ACKNOWLEDGMENTSTATEMENT

Ihaveread,understandandacknowledgethepurposeofthispersonalhistoryquestionnaire(PHQ)andthatIhavefurnishedtherequestedinformationunderthestatedconditions.IhavereadandunderstandtheinformationconcerningNRCrequiredfingerprintsandcriminalhistoryrecord.

IhavebeenadvisedthatanyfalsificationorwillfulomissionofinformationmaybeaviolationofNuclearRegulatoryCommission(NRC)regulations.Thefactsconcerningmycriminalhistoryorfitnessforduty(FFD)recordmaybesubjecttointerpretationbecausedifferentstatesmaycategorizethesameoffensesdifferently.ItisthereforesuggestedthatIdiscloseallpotentiallyderogatoryinformationandreducethelikelihoodofdiscrepanciesbetweentheinformationIhaveprovidedandthatobtainedfromothersources.Failuretolistreasonsforanyprevioussuspension,revocationordenialofUnescortedAccess(UA)toanuclearfacilityorotherentitysubjecttoeitherNRCorFFDregulationmaybesufficientcausefordenialofUAA/UAand/orcivilpenaltiesfromtheNRC.

TheinformationthatIhaveprovidedinthisPHQiscorrectandcompletetothebestofmyknowledgeandbelief.ImakethisstatementwithknowledgethatanyfalseormisleadingstatementoromissionofanyfactmaybesufficientcausefordenialofUAA/UAand/orsafeguardsaccess.IunderstandthattheinformationIhaveprovidedinthisformwillbeverifiedbyauthorizedbackgroundinvestigatorsandwillbeusedonlyforaccessauthorizationpurposes,orotherwiseinaccordancewithapplicablelaw.

IunderstandthatifIamcertifiedUAAorgrantedUA,itismyresponsibility,undertheBehavioralObservationProgram(BOP),toreportanylegalactiontomysupervisorinaccordancewithTennesseeValleyAuthorityNuclearPowerGroup(TVANPG)procedures.ImustalsoreportanylegalactionsfromthetimeIcompletethisPHQuntilIamcertifiedUAAorgrantedUA.AnevaluationwillbemaderegardingtheimpactofthelegalactiononmyUAA/UA.Thedeterminationofwhatconstitutesalegalactionisamatterofstatelawbut,ingeneral,thetermlegalactionmeans:

Aformalactiontakenbyalawenforcementauthorityorcourtoflaw,includingbeingheld,detained,takenintocustody,charged,arrested,indicted,fined,forfeitedbond,cited,orconvictedforaviolationofanylaw,regulationorordinancethisincludesfelony,misdemeanor,serioustrafficoffenses,seriouscivilchargesormilitarychargesbutdoesnotincludeminormisdemeanorssuchasparkingticketsorminorcivilactionssuchaszoningviolationsorminortrafficviolationssuchasmovingviolationswhentheindividualwasnotphysicallytakenintocustody,andincludesthemandatedimplementationofaplanfortreatmentormitigationinordertoavoidapermanentrecordofanarrestorconvictionsinresponsetothefollowing:

(1) theuse,saleorpossessionofillegaldrugs,(2) theabuseoflegaldrugsoralcohol,(3) ortherefusaltotakeadrugoralcoholtest.

Ihavebeenadvisedofmyrighttorequesttoreviewtheinformationdevelopedtoassureitsaccuracyandcompleteness.IunderstandthattheinformationcollectedduringtheconductofthebackgroundinvestigationwillberetainedandmustbemadeavailabletoanyothernuclearpowerplantwhereImayrequestaccess.ItwillonlybeusedindeterminingmyeligibilitytobecertifiedUAA,grantedUAand/orgrantedaccesstosafeguardsinformation.ThisinformationwillberetainedforaperiodoftimeafterthelastterminationofmyUAA/UAordenialofmyUAA/UAand/oraccesstosafeguardsinformation.

ADDITIONALCOMMENTSORNOTES:

TheinformationIhaveprovidedinthisPHQisaccurateandcorrect.

ApplicantsFullPrintedName SocialSecurityNumber

ApplicantsSignature Date


AUTHORIZATION,CONSENT,ANDACKNOWLEDGMENT

Iherebyacknowledgethatinorderformetoworkwithintheprotectedand/orvitalareasofaTennesseeValleyAuthorityNuclearPowerGroup(TVANPG)site,Iamsubjecttoabackgroundinvestigationtodeterminemytrustworthinessandreliability,andconsenttosuchaninvestigationbyTVANPG,itsinvestigativeagents,oritsapprovedcontractors/vendors(C/Vs).Thisinvestigationmayinclude,butisnotlimitedto,averificationofidentity,selfdisclosuredata,employment/unemploymenthistory(includingmilitaryserviceand/oreducationinlieuofemployment),criminalhistory,credithistory,characterreferences,residences,andfitnessfordutyhistory,aswellasamedical/psychologicalevaluation.Thisinformationmaybeobtainedthroughcontactwithfederal,state,andlocalgovernmentalagencies,educationalinstitutions,previousandcurrentemployers,institutionsandindividuals,andothers,whetherornotspecificallymentionedherein,asmayhaverecordsorpersonalknowledgerelatingtomeormyactivities.IauthorizeTVA,itsinvestigativeagents,oritsapprovedC/VstoreleaseallinformationobtainedconcerningmetoanynuclearfacilityortheU.S.NuclearRegulatoryCommission(NRC)fortheirdeterminationofmyeligibilityforunescortedaccess.

Iacknowledgetheinformationcollected/transferredconcerningmepursuanttothisprocessisconsideredconfidentialandisprotectedfromunauthorizeddisclosure.Disclosureisauthorizedunderthefollowingconditions:otherlicensees,C/VsortheirauthorizedrepresentativesseekingtheinformationforUAAdeterminations;NRCrepresentatives;appropriatelawenforcementofficialsundercourtorder;myselformyrepresentative,whoIhavedesignatedinwriting;thoselicenseerepresentativesorC/Vswhohaveaneedtohaveaccesstotheinformationinperformingassigneddutiesincludingauditsoflicensee,contractor,orvendorprograms,exceptwherespecificallyexcludedbyregulation;personsdecidingmattersonrevieworappeal;or,otherpersonspursuanttocourtorderorotherwiseinaccordancewithapplicablelaw.Thesewillbereviewedonacasebycasebasis.IacknowledgethattheresultsofthisinvestigationwillbemaintainedbyTVANPGoritsC/Vsthroughmyperiodofemploymentandforatleastfiveyearsfollowingterminationofmyunescortedaccess.

Iacknowledgethat,uponmyproperrequest,IhavetherighttoreviewtheinformationcollectedduringthebackgroundinvestigationprocessandmaintainedattheTVANuclearAccessServicesofficetoensureitsaccuracyandcompleteness.

Iherebyauthorizeanyperson,agency,organization,orinstitutiontoreleasetoTVANPG,itsinvestigativeagents,orapprovedC/Vssuchinformationasmayberequestedaboutme,basedonadeterminationthattheinformationisnecessaryorappropriateinconnectionwithinvestigatingmeforunescortedaccess.Thisauthorizationspecificallyincludesreleaseofanyandallinformationbymypresentandpreviousemployers,lawenforcementagencies,educationalinstitutions,teachers,professors,landlords,friends,familymembers,andothers,whetherornotspecificallymentionedherein.Theinformationcoveredbythisauthorizationmayinclude,butisnotlimitedto,academic,residential,achievement,performance,attendance,disciplinary,financial,arrestandconvictionrecords,andrecordsrelatingtomymoralcharacterandmentalstability.

IherebywaiveanyandallclaimsagainsttheUnitedStates,TVA,theiremployees,theirC/Vs,theirauthorizedinvestigativeagents,TVAsapprovedC/Vs,andanyperson,agency,organization,orinstitution(includingrecordcustodians)whichprovidesinformationtoTVA,TVAsemployees,orauthorizedinvestigativeagents,forlossordamageofwhateverkindornaturewhichmayatanytimeresultonaccountofcompliance,oranyattemptstocomply,withthisauthorization.

IacknowledgethatdisclosureofinformationisvoluntaryandthatImaywithdrawmyauthorization/consentatanypoint;but,indoingso,Iwillnotbeeligibleforunescortedaccess.

Iacknowledgemyresponsibilitytoreportanylegalactions,includinglegalactionswhichoccurbetweensigningthisformandbeinggrantedUAA/unescortedaccess,toNuclearAccessServicesPlantAccessorCorporateNuclearAccessServices,aswellasmysupervisor,thenextbusinessdayafteranysuchlegalaction.

IhavereadandunderstandallofthetermscontainedinthisAuthorization,Consent,andAcknowledgment.




PrivacyActStatement

Subsection(e)(3)of5U.S.C.552a(Section3ofthePrivacyAct))requiresthatTVAinformyouofitsauthoritytorequestinformationandtheuseswhichTVAmaymakeoftheinformationrequested.ThatsubsectionfurtherrequiresTVAtoinformyouoftheeffectsofnotprovidinganyoralltherequestedinformation.

TVAsauthoritytorequesttheinformationyouwillprovideisderivedfromtheTVAAct(16U.S.C.831831ee),ExecutiveOrderNo.10450,theAtomicEnergyActof1954,asamended,andanumberofotherstatutesandPresidentialExecutiveorders.Informationprovidedonthisformmaybefurnishedtopeople,agencies,organizations,orinstitutionsinordertoobtaininformationregardingyouinconnectionwithaninvestigationtodetermine:(1)fitnessforTVAemployment;(2)clearancetoperformservicesforTVAunderpersonalservices,consultant,orothercontracts;or(3)securityclearanceorclearanceforaccesstoTVAinstallations.

Furnishingtherequestedinformationisvoluntary;however,failuretoprovideallorpartoftheinformationmayresultinalackoffurtherconsiderationforemployment,clearanceoraccess,orintheterminationofyouremployment.

InformationprovidedonthisformisnormallyusedonlytodeterminefitnessforemploymentorsecurityclearanceforaccesstoTVAinstallations.Informationobtainedonthisformmaybefurnishedtothirdpartiesasauthorizedbylaw.Forexample,shouldadisputeariseoracongressionalinquirybemaderegardingTVAemploymentpractices,theinformationmaybemadeavailableoutsideofTVAinthecourseofthatdisputeorinquiry.Further,informationprovidedmaybeprovidedtoanotherfederalagencyifrelevanttoadecisiontobemadebythatagency.Inaddition,informationonthisformmaybemadeavailabletolawenforcementagenciesintheexerciseoftheirduties,ortoaprospectiveemployerorTVAcontractoruponproperrequest.


FAIRCREDITREPORTINGACT

DISCLOSUREANDAUTHORIZATIONSTATEMENT

Forthepurposeofevaluatingmyapplicationforormaintenanceofnuclearpowerplantaccessauthorization,IunderstandTVAoritscontractors/vendorsmayobtainorhavepreparedaconsumerreportorinvestigativeconsumerreportconcerningmyprioremployment,militaryrecord,education,creditworthiness,creditstanding,creditcapacity,character,generalreputation,personalcharacteristics,criminalbackgroundrecord,ormodeofliving.

IunderstandthatuponwrittenrequesttoTVA,Iwillbeinformedwhetheraninvestigativeconsumerreportwasrequested,andgivenfullinformationastothenatureandscopeofthisinvestigation.Iunderstandthataninvestigativeconsumerreportisareportinwhichinformationconcerningmycharacter,generalreputation,personalcharacteristics,ormodeoflivingisobtainedthroughpersonalinterviewswithneighbors,friends,orassociateswithwhomIamacquainted.

Bysigningbelow,IamauthorizingTVA,itscontractors/vendorsoritsinvestigativeagentstoobtainaconsumerorinvestigativeconsumerreportonmeaspartofthescreeningprocessforaccessauthorization.DuringtheperiodinwhichIretainaccessauthorization,Ifurtherauthorizetheobtainingofadditionalconsumerorinvestigativeconsumerreportsonmetoevaluatemytrustworthinessandreliabilityforpurposesofdeterminingandmaintainingcontinuedunescortedaccessauthorization.

Bymysignaturebelow,IalsoacknowledgethatIhavebeenprovidedasummaryofmyrightsundertheFederalFairCreditReportingAct(attachedcopypreparedbytheConsumerFinancialProtectionBureau).

IhavereadandunderstandthisConsentandauthorizeTVAand/oritscontractors/vendorstotakesuchactionsasaredescribedherein.

NameofApplicant:

SocialSecurityNumber:

DateofBirth:

SignatureofApplicant:

Date:

Ifnamechangedbymarriageorotherwise,printformername(s)here:

PrivacyActStatement






PERSONNELACCESSDATASYSTEM(PADS)CONSENTTheTennesseeValleyAuthority(TVA)hasmyconsentto:

a. Collectpersonalinformationaboutmeinordertoverifytheinformationsaccuracy;b. Conductabackgroundinvestigation(BI)inaccordancewithU.S.NuclearRegulatoryCommission(NRC)regulationsto

verifyinformationIhaveprovidedonaPersonalHistoryQuestionnaireandotherinformation,asnecessary;c. Takemyfingerprintsandassociatedbiographicidentifierstoconductacheckofthecriminalhistoryinformation

recordscontainedwithintheFederalBureauofInvestigations(FBIs)IntegratedAutomatedFingerprintInformationSystem(IAFIS).

d. Retainpersonalinformationprovidedforinvestigation;ande. Transferinformationfromotherlicensees,asnecessary,including:(i)informationpertainingtothedenialof

unescortedaccessauthorization(UAA)orunescortedAccess(UA),ordenialofaccesstoanuclearpowerplantunderconstruction,todeterminewhethertocertifyUAA,grantUAtoaU.S.NRClicensedfacilityandtoallowmetomaintainsuchaccess;or(ii)informationpertainingtodenialofaccesstoSafeguardsInformation.

Withtheexceptionofcriminalhistoryrecordinformation(CHRI)collectedunder10CFR73.57,theinformationcollectedwillonlybeusedforthepurposesofdeterminingUAA/UAinaccordancewith10CFR73.56,PersonnelAccessAuthorizationRequirementsforNuclearPowerPlants,separatefitnessforduty(FFD)authorizationinaccordancewith10CFRPart26,FitnessforDutyPrograms,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformationinaccordancewith10CFR73.21,73.22or73.23,ProtectionofSafeguardsInformation,unlessIprovideaseparatereleasetothelicenseeforanotherpurpose.CHRImayonlybeusedforthepurposesofdeterminingwhetherapersonissuitableforunescortedaccesstoanuclearpowerplantorforaccesstoSafeguardsInformation,andmaynotbeusedforanyotherpurpose.IunderstandthatevidenceofcriminalconductdetectedduringtheconductofaBImustbereportedtotheappropriatelawenforcementagencybythelicenseeorcontractor/vendor(C/V).Iauthorizetheuseofsignedcopiesofthisconsenttobeusedinplaceofanoriginallysignedconsentdocument.TheNRCrequiresthattheinformationcollectedbeusedindeterminingthatanindividualistrustworthy,reliable,andfitfordutypriortocertifyingUAA,grantingUA,whilemaintainingUAA/UA;grantingaccesstoanuclearpowerplantunderconstruction;andbeforegrantingaccesstosafeguardsinformation.TheresultsofthisdeterminationmustbeavailabletootherNRClicensedfacilities.AnyofthefollowingactionsrelatedtotheprovidingandsharingofpersonalinformationissufficientcausefordenialorunfavorableterminationofUAA/UA,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformation:

a. Refusaltoprovidewrittenconsentforthebackgroundinvestigationand/orsuitableinquiry;b. Refusaltoprovideinformationorthefalsificationofanypersonalinformationrequiredunder10CFR73.56,Personnel

AccessAuthorizationRequirementsforNuclearPowerPlants,10CFR26,FitnessforDutyPrograms,and/or10CFR73.21,73.22or73.23,ProtectionofSafeguardsInformation,including,butnotlimitedto,thefailuretoreportanypreviousdenialorunfavorableterminationofauthorization;

c. Refusaltoprovidewrittenconsentforthesharingofpersonalinformationwithotherlicenseesorotherentitiesrequiredunder10CFR73.56,PersonnelAccessAuthorizationRequirementsforNuclearPowerPlants,10CFR26,FitnessforDutyPrograms,and/or10CFR73.21,73.22or73.23,ProtectionofSafeguardsInformation;and

d. Failuretoreportanylegalactionsinaccordancewith10CFR73.56(g).

Iunderstandthatthedomesticcommercialnuclearindustryusesacomputerized,restrictedaccessdatasystem,thePersonnelAccessDataSystem(PADS),toshareinformationnecessarytoprocessapplicationsofworkersforUAA/UAtonuclearfacilities,accesstonuclearfacilities,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformation.Ifurtherunderstandthatthissystemisintendedtopermitnuclearfacilitylicenseesandtheiracceptedcontractors/vendorstomeetregulatoryrequirementsmandatingthatcertaininformationbeavailabletoanyfacilitylicenseebyretainingcertainaccessinformationinacentralcomputerdatabase.Iunderstandthattheinformationmaybetransferred,electronicallyorotherwise,tootherlicenseesandcontractor/vendorsortheagentsofeach.Thisinformationwillinclude,butisnotlimitedto:

a. NameandSocialSecurityNumber;b. Placeofbirthandphysicalcharacteristics;


PERSONNELACCESSDATASYSTEM(PADS)CONSENT(continued)c. Dateswhenanyofthefollowingarecompleted:backgroundinvestigation,psychologicalevaluation,fitnessforduty

testing,suitableinquirychecks;d. DateswhenUAA/UA,accesstoanuclearpowerplantconstructionsite,and/oraccesstoSafeguardsInformationhas

beenauthorizedorterminated;e. DateofanydenialofUAA/UA,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguards

Informationandthecompanyholdingtherelevantinformation;f. DatesassociatedwithFFDtesting(preaccess,postevent,forcauseandfollowup)andtreatment;g. Annualradiationexposurehistory;h. Respiratoryequipmentqualification/fittesting;i. Medicalqualificationforrespiratoruse;j. DataconcerningtrainingrequiredforUAA/UA,accesstoanuclearpowerplantconstructionsite,accesstoSafeguards

Informationandworkqualification;andk. Directiontoseekadditionalinformationdirectlyfromanotherlicensee.

Iauthorizeanyindividual,organization,institution,orentitythatnowhas,orobtainsinthefuture,accessrelatedinformationaboutme(examplesofwhichareprovidedintheaboveparagraph),whetherornotsuchinformationisincludedinthePADSdatabase,toreleaseanysuchinformationinordertoperformtheinvestigationandevaluationrequiredforUAA/UA,accesstoanuclearpowerplantconstructionsiteand/oraccesstoSafeguardsInformation.IunderstandthatinformationcontainedwithinanFBIcriminalhistoryrecordwillberestrictedtotheNRC,nuclearlicenseefacilitiesregulatedbytheNRC,andmyself,andthatthecriminalhistoryinformationwillnotbereleasedtocontractor/vendorsortheiragents.IauthorizetheentryintothePADScomputerdatabaseofanyinformationcollectedforthepurposeofprocessingmyapplicationfor,orcontinuedmaintenanceof,UAA/UA,accesstoanuclearpowerplantconstructionsite,and/oraccesstoSafeguardsInformation.Iauthorizethetransferofsuchinformation,electronicallyorotherwise,tootherNRCnuclearfacilitylicenseesandcontractors/vendors.Iauthorizesuchlicenseesandcontractors/vendorstousethedatabaseinformationforthepurposeofdeterminingmyeligibilityforUAA/UA,foraccesstoanuclearpowerplantconstructionsite,and/orforaccesstoSafeguardsInformation.IunderstandthatinformationobtainedpursuanttothisConsentshallbetreatedasconfidential.ThereleaseofaccessrelatedinformationaboutmeshallbelimitedtoregulatoryagenciesandsuchemployeesofNRCfacilitylicenseesandtheircontractors/vendorswhohavebeendesignatedashavinganeedtoknowtheinformationinordertodotheirjobs.Thefollowingisalistingofindividualsthatmayaccessinformationwithoutmyconsentinordertoperformtheirofficialduties:

a. Myselformyrepresentative,whenIhavedesignatedtherepresentativeinwritingforspecifiedUAA/UA,nuclear

powerplantconstructionsiteaccess,safeguardsinformationaccessand/orFFDmatters;b. AssignedMedicalReviewOfficers(MROs)andMROstaff;c. NRCrepresentatives;d. Appropriatelawenforcementofficialsundercourtorder;e. licensee,contractor/vendor,ortheiragentswhohaveaneedtohaveaccesstotheinformationtoperformtheir

assigneddutiesundertheUAA/UA,nuclearpowerplantconstructionsiteaccess,safeguardsaccess,and/orFFDprograms,includingdeterminationsoffitness,accessauthorizationorFFDprogramaudits,andsomehumanresourcesfunctions;

f. Thepresidingofficerinajudicialoradministrativeproceedingthatisinitiatedbythesubjectindividual;g. PersonsdecidingmattersunderaccessauthorizationorFFDprogramappealprocess;andh. Otherpersonspursuanttocourtorder.

Iunderstandthatallinformationaboutmeinthedatabasewillbemaintainedassecurelyasreasonablypracticableforaperiodofatleast5yearsafterUAA/UA,accesstoanuclearpowerplantconstructionsite,and/oraccesstoSafeguardsInformationislastterminated.ThetypesofrecordsmaintainedincludedocumentationcollectedduringtheadministrationoftheaccessauthorizationandFFDprograms.Alldocumentspertainingtoa5yearorpermanentdenial


PERSONNELACCESSDATASYSTEM(PADS)CONSENT(continued)ofUAA/UArequiredby10CFR26willberetainedbyalicenseemakingthedenialorunfavorableterminationofUAA/UAfor40yearsortheNRCdeterminesthattherecordsarenolongerneeded.TherecordsofFFDtrainingandexaminationsconductedunder10CFR26and10CFR73.21,73.22,or73.23willbemaintainedforatleast3years.RecordsidentifiedarenormallymaintainedattheTVANuclearAccessServicesoffice.IunderstandthatifIdeterminethatinaccordancewith28CFR16.34,Proceduretoobtainchange,correctionorupdatingofidentificationrecordsIf,afterreviewingmyidentificationrecord,Ibelievethatitisincorrectorincompleteinanyrespectandwishchanges,correctionsorupdatingoftheallegeddeficiency,Imaymakeapplicationdirectlytotheagencywhichcontributedthequestionedinformation.ImayalsodirectmychallengeastotheaccuracyorcompletenessofanyentryonyourrecordtotheFBI,CriminalJusticeInformationServices(CJIS)Division,ATTN:SCU,Mod.D2,1000CusterHollowRoad,Clarksburg,WV26306.TheFBIwillthenforwardthechallengetotheagencywhichsubmittedthedatarequestingthatagencytoverifyorcorrectthechallengedentry.Uponthereceiptofanofficialcommunicationdirectlyfromtheagencywhichcontributedtheoriginalinformation,theFBICJISDivisionwillmakeanychangesnecessaryinaccordancewiththeinformationsuppliedbythatagency.IunderstandthatIhavearighttoreviewinformationcollectedandmaintainedbyTVAtoassureitisaccurateandcompleteandtocorrectanyinaccurateorincompleteinformation.Iunderstandthat,uponmywrittenrequesttoTVA,andatnocosttome,Iwillbeprovided,within10businessdays,withaprintedcopyoftheinformationaboutmewhichisrecordedinthedatabase.If,aftermyreviewofsuchinformation,Icanshowthatanyoftheinformationisincorrectorincomplete,suchinformationwillbecorrectedand/orcompletedassoonasisreasonablypractical.IunderstandthatatanytimeanduponwrittennoticetoTVA,ImaywithdrawthisConsent,butthiswillalsoconstituteawithdrawalofmyrequestforaccess.Iunderstandthatanyprocessingactivitiesthatwereinitiatedbeforereceiptofmywithdrawalofconsentshallcontinueandtheresultinginformationwillberetainedinthedatabase.Nonewinquiriesshallbeinitiatedafterreceiptofmywithdrawalofconsent.Thereafter,PADSparticipantsarenotpermittedtoretrieveinformationfromthedatabaseotherthanmyname,dateofbirth,identificationnumber,andthefactthatmyconsenthasbeenwithdrawn,unlessIprovideacurrentlyvalidConsentortheinformationsoughtisrequiredbyNRCregulation.IherebyreleaseTVA,otherPADSparticipants,NEI,andtheofficers,employees,representatives,agents,andrecordscustodiansofeachaswellastheofficers,employees,representatives,agents,andrecordscustodiansofanyentityorindividualsupplyingorusingsuchinformationfromanyandallliabilitybasedontheirauthorizedreceipt,disclosure,oruseoftheinformationobtainedpursuanttothisConsentandtodeterminemyeligibilityforUAA/UAtonuclearfacilities,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformation.IunderstandthatthisConsentisnotintendedtoanddoesnotaffectanyrightorresponsibilitythatI,myemployer(ifnotTVA),orTVAmayhaveunderSection211oftheEnergyReorganizationActof1974,asamended.Ifurtherunderstandthatnothingherein(1)affectsmyrightormyresponsibilitytobringpotentialsafetyconcernstomyemployer(ifnotTVA),TVA,ortheNRC;or(2)prohibitsmefromparticipatinginanyproceedingorinvestigationregardingsuchapotentialsafetyconcern.IhavereadandunderstandthisConsentandauthorizeTVAtotakesuchactionsasaredescribedhereinorspecifiedbyPADSprocedures.WhileIunderstandthatUAA/UA,accesstoanuclearpowerplantconstructionsiteand/oraccesstoSafeguardsInformationisdependentuponmyacceptingtheregulatoryrequirementsofthisprogram,thestatementsmadebymeinthisConsentandmydecisiontosignthisConsentarevoluntary.ThestatementswerenotinducedbyanypromisenorhaveIbeensubjectedtoanythreat,duressorcoerciontosignthisConsent.




PrivacyActStatement






SELFDISCLOSURE

TheNuclearRegulatoryCommissionrequiresthatthecompanyinvestigateyourpreviousemploymenthistoryandmakeinquiriesofemployerstodeterminewhetherornotthereareanyfitnessforduty(FFD)concernsthatmustbeexploredandevaluatedpriortocertifyingUAAorgrantingUA.

AnswereachquestionbycheckingeitherYesorNoasitpertainstoyou.ForeachYesanswerincludethespecifictypeofissue,durationandresolution,including,butnotlimitedtothereasonforanunfavorableterminationordenialofUAA/UA.Detailsmayinclude,butarenotlimitedto,date,nameandlocationoftheemployerorpotentialemployerinvolved(towhomyouappliedforemployment),natureoftheviolation,anyhearing,penaltyimposedorotherdisposition.

InitialWithinthelastfive(5)years,orsinceyour18thBIRTHDAY(whicheverisshorter),haveyou:Update/ReinstatementSinceyourlastUA/UAAiffavorablyterminatedwithinthepast3years,haveyou: (CheckYesorNo)

1. violatedalicenseeoremployersfitnessfordutypolicy? Yes No

2.beendeniedorhadunescortedaccessauthorizationterminatedunfavorablyatanyplaceofemploymentoratanynuclearpowerplantforanyreasonincludingfitnessfordutypolicyviolationorbeenunfavorablyterminatedfromanyemploymentforafitnessfordutyreason?

Yes No

3. used,sold,orpossessedillegaldrugs? Yes No

4. abusedlegaldrugsoralcohol? Yes No

5. eversubvertedorattemptedtosubvertadrugoralcoholtestingprogram? Yes No

6. refusedtotakeadrugoralcoholtest? Yes No

7. beensubjecttoaplan(exceptselfreferral)fortreatingsubstanceabuse? Yes No

8.beensubjecttoalawenforcementauthorityorcourtoflawactionforalcoholordruguserelatedtoanyofthefollowing:

(a)Theuse,saleorpossessionofillegaldrugs? Yes No

(b)Theabuseoflegaldrugsoralcohol? Yes No

(c)Therefusaltotakeadrugoralcoholtest? Yes No

9. beensubjecttoemploymentactiontakenforalcoholordrugabuseinvolvinganyofthefollowing:

(a)Achangeinjobresponsibilitiesorremovalfromajob? Yes No

(b)Mandatedimplementationofaplanforsubstanceabusetreatmentinordertoavoidachangeinorremovalfromajob?

Yes No

10. Areyoucurrentlyinafitnessfordutyfollowuptestingprogram? Yes No

ExplainanyYESanswers,includingdate(s),location(s),anddescriptionofincident(s):




PrivacyActStatement






CRIMINALHISTORY

CAUTION:Providingfalseordeliberatemisleadingstatementsoromissionoffactsmaybesufficientgroundsfordenialofunescortedaccess.Ifyouwerefingerprinted,reporttheoccurrence.Ifyoucurrentlyhaveanycriminalchargespending,reportthecharge.Youmustlistfelony,misdemeanor,trafficormilitarycriminalhistorytoincludecourtmartialornonjudicialpunishmentincludingguiltypleasandnolocontendere(meaningnocontest);anysuspendedsentences,pretrialdiversions,dismissals,nolleprosequi(meaningnotprosecuted).(Youmayomitnoninjurytraffic,parkingoffensesoflessthan$200orminorcivilactionssuchaszoningviolations,whenyouwerenotphysicallytakenintocustody,butyoumustincludeanyalcohol/drugrelatedtrafficoffensesregardlessofamountoffine.)

InitialSinceyour18thBIRTHDAY,haveyou:Update/ReinstatementSinceyourlastUA/UAAifwithin3years,haveyou: (Check Yes or No)

1. Beenheld,detained,takenintocustody,charged,arrested,indicted,fined,forfeitedbond,cited,orconvictedforaviolationofanylaw,regulationorordinance(e.g.,felony,misdemeanor,trafficormilitarycriminalhistory,etc.)ordoyounowhavesuchacasepending? Yes No

2. Beencharged,arrestedorconvictedofanalcoholoracontrolledsubstancerelatedoffense,whichincludes:drivingunder

theinfluence/whileintoxicated(DUI/DWI),orhavesuchacasepending? Yes No

3. Beencharged,arrestedorconvictedofaninfractionofthelawforwhichyouwerefinedmorethan$200? Yes No

4. Failedtoappearincourtforanyoffense(s)? Yes No

5. Areyoucurrentlyunderindictment,onprobation,parole,workrelease,orsubjecttoanyothercontrolofacourt(includingrestrainingorders,ordersofprotection)? Yes No

IfyouansweredYestoanyquestionabove,listalloccurrencesbelowandprovidespecificdetailsinthespaceprovidedonthenextpage.Addcontinuationpagesasnecessary.

Date(Mo/Day/Yr) Offense CityandStateofOffense

Misdemeanor Felony

Disposition/CurrentStatus(i.e.,guilty,

dismissed,fined,pending(listamount))

TheNuclearRegulatoryCommissionrequiresthatindividualswithUAA/UAatNuclearPowerPlantsreportLegalActions.Alegalactionwillbejudgedbaseduponitspotentialtoimpactuponyourtrustworthiness.ThisispartoftheBehavioralObservationProgram.YoumustalsoreportanylegalactionsfromthetimeyoucompletethisPHQuntilgrantedUAA.SuchlegalactionswillbeconsideredindeterminingyourreliabilityandtrustworthinessandTVAsdecisionwhethertograntormaintainyourUnescortedAccess.




FINGERPRINTINFORMATIONFORFBICRIMINALHISTORYTheNuclearRegulatoryCommissionregulation(10CFR73.57)whichimplementsPublicLaw99399"OmnibusDiplomaticSecurityAndAntiTerrorismActOf1986"requireslicenseestotakethefingerprintsofpersonsseekingunescortedaccesstonuclearpowerfacilitiesoraccesstosafeguardsinformationandsubmitthoseprintstotheFBIrequestingcriminalhistorychecks.Inaccordancewith28CFR16.34,Proceduretoobtainchange,correctionorupdatingofidentificationrecordsIf,afterreviewingyouridentificationrecord,youbelievethatitisincorrectorincompleteinanyrespectandwishchanges,correctionsorupdatingoftheallegeddeficiency,youshouldmakeapplicationdirectlytotheagencywhichcontributedthequestionedinformation.YoumayalsodirectyourchallengeastotheaccuracyorcompletenessofanyentryonyourrecordtotheFBI,CriminalJusticeInformationServices(CJIS)Division,ATTN:SCU,Mod.D2,1000CusterHollowRoad,Clarksburg,WV26306.TheFBIwillthenforwardthechallengetotheagencywhichsubmittedthedatarequestingthatagencytoverifyorcorrectthechallengedentry.Uponthereceiptofanofficialcommunicationdirectlyfromtheagencywhichcontributedtheoriginalinformation,theFBICJISDivisionwillmakeanychangesnecessaryinaccordancewiththeinformationsuppliedbythatagency.Yourcriminalrecordorpersonalinformationcollectedandmaintainedasaresultofthefingerprintsmaynotbedisclosedtopersonsotherthanyourself,yourauthorizedrepresentative,ortothosewhohaveaneedtoknowtheinformationinperformingassigneddutiesintheprocessofgrantingordenyingunescortedaccesstothenuclearpowerfacilityoraccesstosafeguardsinformation.TheinformationobtainedfromacriminalhistoryrecordcheckwillbemadeavailabletoanyotherNRClicenseepursuanttoanaccessclearanceforyouatanotherfacility.Inaccordancewith28CFR16.32,Proceduretoobtainanidentificationrecord,youmayobtainacopythereofbysubmittingawrittenrequestviatheU.S.mailsdirectlytotheFBI,CriminalJusticeInformationServices(CJIS)Division,ATTN:SCU,Mod.D2,1000CusterHollowRoad,Clarksburg,WV26306.Suchrequestmustbeaccompaniedbysatisfactoryproofofidentity,whichshallconsistofname,dateandplaceofbirthandasetofrolledinkedfingerprintimpressionsplaceduponfingerprintcardsorformscommonlyutilizedforapplicantorlawenforcementpurposesbylawenforcementagencies.CriminalhistoryinformationobtainedthroughtheFBImayalsobemadeavailableforexaminationbyauthorizedrepresentativesoftheNRCinthecourseoftheirdutiestodeterminecompliancewithregulationsandlaws.ThecriminalhistoryrecordinformationwillberetainedasrequiredbyregulationafterUAA/UAtothenuclearpowerfacilityortosafeguardsinformationhasbeendeniedorterminated. Ihavethefollowingadditionalcommentsconcerningcriminalhistory:



PrivacyActStatement






NOTIFICATIONOFLEGALACTION

Individualsapplyingfor,certifiedfor,grantedormaintainingUnescortedAccessAuthorization(UAA),orUnescortedAccess(UA),orFitnessforDutyAuthorization(FFDA)atnuclearpowerplantsmustreportlegalactionsfromthetimetheindividualsignsthePersonalHistoryQuestionnaire(PHQ)uptoandincludingthetimethattheindividualUAA/UA/FFDAisterminated.Legalactionswillbejudgedbaseduponthepotentialtoimpactuponyourtrustworthiness.ThisispartoftheBehavioralObservationProgram(BOP).

Tocomplywithregulatoryrequirements,youarerequiredtoreportANYlegalaction(youmayomitnoninjurytrafficorparkingoffensesoflessthan$200butyoumustincludeanyalcohol/drugrelatedtrafficoffensesregardlessofamountoffine)inwriting,toNuclearAccessServicesPlantAccessorNuclearAccessServicesCorporateandyoursupervisornolaterthanthenextbusinessdayafterthelegalactionoccurred.YoumustalsoreportanylegalactionsfromthetimeyoucompletethisPHQuntilgrantedUnescortedAccess.Youarealsorequiredtoreportanychangesinthestatusofanylegalactionbythenextbusinessday(i.e.,changesincourtdate,chargesdropped,arrestresultinginconviction,placedonprobation,parole,workrelease,orsubjecttoanyothercontrolofthecourt.)Alegalactionisdefinedas:

Aformalactiontakenbyalawenforcementauthorityorcourtoflaw,includingbeingheld,detained,takenintocustody,charged,arrested,indicted,fined,forfeitedbond,cited,orconvictedforaviolationofanylaw,regulationorordinance.

Thisincludesfelony,misdemeanor,serioustrafficoffenses,seriouscivilchargesormilitarychargesbutdoesnotincludeminormisdemeanorssuchasparkingticketsorminorcivilactionssuchaszoningviolationsorminortrafficviolationssuchasmovingviolationswhentheindividualwasnotphysicallytakenintocustody,

Italsoincludesthemandatedimplementationofaplanfortreatmentormitigationinordertoavoidapermanentrecordofanarrestorconvictionsinresponsetothefollowing:(1)Theuse,saleorpossessionofillegaldrugs;(2)Theabuseoflegaldrugsoralcohol;or(3)Therefusaltotakeadrugoralcoholtest.

Thisdoesnotincludeminormisdemeanorssuchasparkingtickets,minorcivilactions,suchaszoningviolations,orminortrafficviolationssuchasmovingviolationswhentheindividualwasnotphysicallytakenintocustody,providedthelegalactiondidnotincludeuse.Sale,orpossessionofillegaldrugs;abuseoflegaldrugsoralcohol;orrefusaltotakeadrugoralcoholtest.

Failuretoreportalegalactionasrequiredmayresultindenial,suspension,revocation,orwithdrawalofUAA/UAorFFDA,anddisciplinaryactionuptoandincludingdischarge.Bymysignaturebelow,IcertifythatIhavereadthisnotificationandunderstandmyobligationtoreportlegalactionsfromthesigningofthisdocumentuntilauthorizationisterminated.




Parainformacionenespanol,visitewww.consumerfinance.gov/learnmoreoescribealaConsumerFinancialProtectionBureau,1700GStreetN.W.,Washington,D.C.20552.

ASummaryofYourRightsUndertheFairCreditReportingAct

ThefederalFairCreditReportingAct(FCRA)promotestheaccuracy,fairness,andprivacyofinformationinthefilesofconsumerreportingagencies.Therearemanytypesofconsumerreportingagencies,includingcreditbureausandspecialtyagencies(suchasagenciesthatsellinformationaboutcheckwritinghistories,medicalrecords,andrentalhistoryrecords).HereisasummaryofyourmajorrightsundertheFCRA.Formoreinformation,includinginformationaboutadditionalrights,gotowww.consumerfinance.gov/learnmoreorwriteto:ConsumerFinancialProtectionBureau1700GStreetN.W.,Washington,D.C.20552. YoumayhaveadditionalrightsunderMainesFCRA,ME.Rev.Stat.Ann.10,Sec1311etseq.

Youmustbetoldifinformationinyourfilehasbeenusedagainstyou.Anyonewhousesacreditreportoranothertypeofconsumerreporttodenyyourapplicationforcredit,insurance,oremploymentortotakeanotheradverseactionagainstyoumusttellyou,andmustgiveyouthename,address,andphonenumberoftheagencythatprovidedtheinformation.

Youhavetherighttoknowwhatisinyourfile.Youmayrequestandobtainalltheinformationaboutyouinthefilesofaconsumerreportingagency(yourfiledisclosure).Youwillberequiredtoprovideproperidentification,whichmayincludeyourSocialSecuritynumber.Inmanycases,thedisclosurewillbefree.Youareentitledtoafreefiledisclosureif:

o apersonhastakenadverseactionagainstyoubecauseofinformationinyourcreditreport;o youarethevictimofidentitytheftandplaceafraudalertinyourfile;o yourfilecontainsinaccurateinformationasaresultoffraud;o youareonpublicassistance;o youareunemployedbutexpecttoapplyforemploymentwithin60daysInaddition,allconsumersareentitledtoonefreedisclosureevery12monthsuponrequestfromeachnationwidecreditbureauandfromnationwidespecialtyconsumerreportingagencies.Seewww.consumerfinance.gov/learnmoreforadditionalinformation.

Youhavetherighttoaskforacreditscore.Creditscoresarenumericalsummariesofyourcreditworthinessbasedon

informationfromcreditbureaus.Youmayrequestacreditscorefromconsumerreportingagenciesthatcreatescoresordistributescoresusedinresidentialrealpropertyloans,butyouwillhavetopayforit.Insomemortgagetransactions,youwillreceivecreditscoreinformationforfreefromthemortgagelender.

Youhavetherighttodisputeincompleteorinaccurateinformation.Ifyouidentifyinformationinyourfilethatisincompleteorinaccurate,andreportittotheconsumerreportingagency,theagencymustinvestigateunlessyourdisputeisfrivolous.Seewww.consumerfinance.gov/learnmoreforanexplanationofdisputeprocedures.

Consumerreportingagenciesmustcorrectordeleteinaccurate,incomplete,orunverifiableinformation.Inaccurate,incompleteorunverifiableinformationmustberemovedorcorrected,usuallywithin30days.However,aconsumerreportingagencymaycontinuetoreportinformationithasverifiedasaccurate.

Consumerreportingagenciesmaynotreportoutdatednegativeinformation.Inmostcases,aconsumerreportingagencymaynotreportnegativeinformationthatismorethansevenyearsold,orbankruptciesthataremorethan10yearsold.

Accesstoyourfileislimited.Aconsumerreportingagencymayprovideinformationaboutyouonlytopeoplewithavalidneedusuallytoconsideranapplicationwithacreditor,insurer,employer,landlord,orotherbusiness.TheFCRAspecifiesthosewithavalidneedforaccess.

Youmustgiveyourconsentforreportstobeprovidedtoemployers.Aconsumerreportingagencymaynotgiveoutinformationaboutyoutoyouremployer,orapotentialemployer,withoutyourwrittenconsentgiventotheemployer.Writtenconsentgenerallyisnotrequiredinthetruckingindustry.Formoreinformation,gotowww.consumerfinance.gov/learnmore.

Youmaylimitprescreenedoffersofcreditandinsuranceyougetbasedoninformationinyourcreditreport.Unsolicitedprescreenedoffersforcreditandinsurancemustincludeatollfreephonenumberyoucancallifyouchoosetoremoveyournameandaddressfromtheliststheseoffersarebasedon.Youmayoptoutwiththenationwidecreditbureausat18885678688).

Youmayseekdamagesfromviolators.Ifaconsumerreportingagency,or,insomecases,auserofconsumerreportsorafurnisherofinformationtoaconsumerreportingagencyviolatestheFCRA,youmaybeabletosueinstateorfederalcourt.

Identitytheftvictimsandactivedutymilitarypersonnelhaveadditionalrights.Formoreinformation,visitwww.consumerfinance.gov/learnmore.


StatesmayenforcetheFCRA,andmanystateshavetheirownconsumerreportinglaws.Insomecases,youmayhavemorerightsunderstatelaw.Formoreinformation,contactyourstateorlocalconsumerprotectionagencyoryourstateAttorneyGeneral.Forinformationaboutyourfederalrights,contact: TYPEOFBUSINESS: CONTACT:

1.a,Banks,savingsassociations,andcreditunionswithtotalassetsofover$10billionandtheiraffiliates.b,Suchaffiliatesthatarenotbanks,savingsassociations,orcreditunionsalsoshouldlist,inadditiontotheBureau:

a,BureauofConsumerFinancialProtection1700GStreetNWWashington,DC20006b,FederalTradeCommission:ConsumerResponseCenterFCRAWashington,DC20580(877)3824357

2.Totheextentnotincludedinitem1above:

a.Nationalbanks,federalsavingsassociations,andfederalbranchesandfederalagenciesofforeignbanks

b.Statememberbanks,branchesandagenciesofforeignbanks(otherthanfederalbranches,federalagencies,andinsuredstatebranchesofforeignbanks),commerciallendingcompaniesownedorcontrolledbyforeignbanks,andorganizationsoperatingundersection25or25AoftheFederalReserveAct

c.NonmemberInsuredBanks,InsuredStateBranchesofForeignBanks,andinsuredstatesavingsassociationsd.FederalCreditUnions

a. OfficeoftheComptrolleroftheCurrencyCustomerAssistanceGroup1301McKinneyStreet,Suite3450Houston,TX770109050b. FederalReserveConsumerHelpCenterP.O.Box1200Minneapolis,MN55480c. FDICConsumerResponseCenter1100WalnutStreet,Box#11KansasCity,MO64106

d,NationalCreditUnionAdministrationOfficeofConsumerProtection(OCP)DivisionofConsumerComplianceandOutreach(DCCO)1775DukeStreetAlexandria,VA22314

3.Aircarriers Asst.GeneralCounselforAviationEnforcement&ProceedingsDepartmentofTransportation400SeventhStreetSWWashington,DC20590

4.CreditorsSubjecttoSurfaceTransportationBoard OfficeofProceedings,SurfaceTransportationBoardDepartmentofTransportation1925KStreetNWWashington,DC20423

5.CreditorsSubjecttoPackersandStockyardsAct

NearestPackersAndStockyardsAdministrationareasupervisor

6.SmallBusinessInvestmentCompanies..

AssociateDeputyAdministratorforCapitalAccess

UnitedStatesSmallBusinessAdministration

406ThirdStreet,SW,8thFloor

Washington,DC20416

7.BrokersandDealers

SecuritiesandExchangeCommission

100FStNE

Washington,DC20549

8.FederalLandBanks,FederalLandBankAssociations,FederalIntermediateCreditBanks,andProductionCreditAssociations

FarmCreditAdministration1501FarmCreditDrive

McLean,VA221025090

9.Retailers,FinanceCompanies,andAllOtherCreditorsNotListedAbove

FTCRegionalOfficeforregioninwhichthecreditoroperatesorFederalTradeCommission:ConsumerResponseCenterFCRA

Washington,DC20580

(877)3824357

tennessee valley authoritymulti.tva.gov/contractor/forms/tva/tva_personal_history... · tva 40932...

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