DEPARTMENT OF HEALTH AND HUMAN SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

IDENTIFICATION (ID) BADGE REQUEST
(Other Federal Departments may call this type of ID badge a Personal Identity Verification [PIV] card)

APPLICANT INSTRUCTIONS FOR COMPLETING FORM HHS-745, “HHS ID BADGE REQUEST”

Section A collects identifying information about Applicants needed to issue an HHS ID Badge. In some Federal agencies, Sponsors
or other authorized officials will complete this section for Applicants. If you are an Applicant and are asked to complete Section A,
follow the instructions below. During the ID Badge issuing process, you also will be asked to complete Section F.

Clearly print all information except for your signature.

SECTION A
1. Check the appropriate box to indicate why a new HHS ID Badge is being issued. If you check “Other,” please indicate the reason
in the space provided.
2. Enter your full legal name on the first line. If you have used other name(s), enter these names on the “Other Name(s) Used” line.
3. Enter your date of birth in mm/dd/yyyy format.
4. Enter your place of birth (city and state if born in the U.S. or city and country if foreign born).
5. Enter your Social Security Number (xxx-xx-xxxx).
6. Check whether you are a U.S. citizen. If you are not a U.S. citizen, enter the country where you are a citizen.
7. Enter your position title (include series and grade level).
8. Enter where you will be working. This could include the center, office, group, division, or institute. If you are a contractor
Applicant, enter the organizational chain for the COTR’s or Project Officer’s division.
9. Enter the physical location (building and office) of your office, work area, or contract office.
10. Enter your work telephone number. If none, then list Contract Officer’s, COTR’s, or Project Officer’s telephone number.
11. Enter your email address.
Contractors and others employed outside the Federal government, complete items 12 through 14.

12. Enter your company’s name.

13. Enter your company’s address.
14. Enter your company’s telephone number.
All Applicants complete items 15 and 16.

15. Sign to authorize HHS to conduct the identity proofing/verification process and to certify that you understand that actions may
be taken against you if you provide false information on this form.
16. Enter the date you signed.

SECTIONS B, C, D, AND E WILL BE COMPLETED BY HHS.

SECTION F
You will be given a copy of the Privacy Act Statement for this HHS ID Badge Request form and HHS ID Badge Rules.
72. Sign your name to certify that you have read and understand the Privacy Act Statement and HHS ID Badge Rules and that you
agree to follow the HHS ID Badge rules.
73. Enter the date of your signature.

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 DEPARTMENT OF HEALTH AND HUMAN SERVICES
DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
IDENTIFICATION (ID) BADGE REQUEST
(Other Federal Departments may call this type of ID badge a Personal Identity Verification [PIV] card)

Privacy Act Statement: The information on this form is collected by the Department of Health and Human Services (HHS) to issue
you an identification badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of
government buildings, the people who work in them, and government computer systems. When you use your ID Badge an ID Badge
system will verify that you are authorized to use government facilities. The system also will track and control the ID Badges that
are issued. The authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal
Facilities, June 28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social
Security number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying
your identity to process this application. The information on this form may be disclosed only with your written consent, except where
permitted by the Privacy Act. The disclosures permitted by the Privacy Act include disclosure to: the Department of Justice, a court,
or other government officials when the records are relevant and necessary to a law suit; the appropriate public authority (Federal,
foreign, State, local, tribal, or otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation;
a Member of Congress or congressional staff member at your written request; the National Archives and Records Administration
for records management inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to
do agency work and who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide
whether to retain an employee, continue a security clearance, or agree to a contract, grant, license or benefit; Federal, State, or local
agencies, entities, individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Office of
Management and Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is
no longer valid. If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will
not have access to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the
information may prevent you from being able to work.

A. Applicant Information (To be completed by Applicant, Sponsor, or Authorized Official)

1. REASON FOR ISSUANCE
New Application Renewal Lost Stolen Damaged Expired
Other (specify):
2. NAME (Last, First, Middle) OTHER NAME(S) USED

3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH

City ZIP Code State or Province Country

5. SOCIAL SECURITY NUMBER (xxx-xx-xxxx) 6. U.S. CITIZEN

Yes No (specify citizenship):

7. POSITION TITLE 8. AGENCY / DIVISION

FDA
9. BUILDING / OFFICE ADDRESS 10. WORK PHONE
6003 Executive Blvd, Suite 400, Rockville, MD 20852
11. EMAIL

For Contractors, complete lines 12 through 14

12. ORGANIZATION / COMPANY NAME 13. ADDRESS OF ORGANIZATION / COMPANY
GDIT 6003 Executive Blvd, Suite 400, Rockville, MD 20852
14. TELEPHONE OF ORGANIZATION / COMPANY

To be completed by Applicant
I hereby authorize the release of information in this application to appropriate Federal agencies for the purposes of processing this application and
verifying my identity. I also acknowledge that if I knowingly provide or assist in the provision of false information or non-verifiable information, and/or I
purposely omit information, it could result in loss of access to HHS facilities and IT systems and in disciplinary action including removal from Federal
service or a Federal contract, and I may be subject to prosecution under applicable Federal criminal and civil statutes.
15. APPLICANT SIGNATURE 16. DATE (mm/dd/yyyy)

HHS-745 (09/18) PAGE 1 of 5 PSC Publishing Services (301) 443-6740 EF

 APPLICANT NAME:
B. HHS ID BADGE REQUEST (To be completed by Sponsor, after Section A has been completed)
17. ID BADGE TYPE (choose one)
HHS Employee Contractor CAC to be Bound Organizational Affiliate

18. POSITION DESCRIPTION NUMBER 19. ADDITIONAL ACCESS NEEDED (list room #'s)

20. NOT TO EXCEED DATE (mm/dd/yyyy)

For Contractors, complete lines 21 through 30

PROJECT OFFICER INFORMATION (if not Sponsor)
21. NAME (Last, First, Middle) 27. CONTRACT START (mm/dd/yyyy)
Orozco, J. Jesus 08/25/2009
22. CENTER/OFFICE/GROUP/DIVISION 28. CONTRACT EXPIRATION (mm/dd/yyyy)
OO/OIMT/OIM/OTD/DAS/MPB/CDERT 05/14/2023
23. POSITION TITLE I certify that the above Applicant will be participating on the contract identified on
this form.
IT Manager
24. WORK PHONE 25. EMAIL 29. PROJECT OFFICER SIGNATURE
(301) 796-7767 [Link]@[Link]
26. APPLICANT CONTRACT NO. 30. DATE (mm/dd/yyyy)
GS-35F-088AA
SPONSOR INFORMATION
31. NAME (Last, First, Middle) 34. POSITION TITLE
Spurlock, David Management Analyst
32. HHS ID NUMBER 35. WORK PHONE
(240) 402-4660
33. AGENCY/DIVISION 36. EMAIL
OO/OIMT/OIM/OTD/DAS [Link]@[Link]
I agree to sponsor the above Applicant for an HHS ID Badge and certify that the information provided in Sections A and B are complete and
accurate to the best of my knowledge. I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifiable
information, and/or I purposely omit information, I may be subject to disciplinary action up to and including removal from the Federal service and I
may be subject to prosecution under applicable Federal criminal and civil statutes.
37. SPONSOR SIGNATURE 38. DATE (mm/dd/yyyy)

C. IDENTITY PROOFING (To be completed by Sponsor, Enrollment Official, or Registrar after Section B has been completed)
39. DID APPLICANT PRESENT TWO FORMS OF IDENTIFICATION, ONE IDENTITY PROOFER INFORMATION

OF WHICH WAS A PHOTO ID ISSUED BY A STATE OR THE FEDERAL 40. NAME (Last, First, Middle)

GOVERNMENT?
41. IDENTITY PROOFER HHS ID NUMBER
Yes No

IDENTITY SOURCE DOCUMENT ONE IDENTITY SOURCE DOCUMENT TWO

42. NAME 45. NAME

43. DOC. TITLE 46. DOC. TITLE

44. DOC. EXPIRATION DATE (mm/dd/yyyy) 47. DOC. EXPIRATION DATE (mm/dd/yyyy)

I certify that the above Applicant appeared before me and presented two ID source documents, which to the best of my knowledge appeared to be
genuine, or presented an undamaged uncompromised, unexpired HHS ID Badge and does not require a background investigation. I hereby
acknowledge that if I knowingly provide or assist in the provision of false information, non- verifiable information, and/or I purposely omit information,
I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under applicable
Federal criminal and civil statutes.

48. ID PROOFER SIGNATURE 49. DATE (mm/dd/yyyy)

HHS-745 (09/18) PAGE 2 of 5

 APPLICANT NAME:
D. HHS ID BADGE APPROVAL (To be completed by Registrar, after Section C has been completed)
If the Applicant does not require a background investigation and is in possession of an undamaged, uncompromised, unexpired HHS
ID Badge, you may complete all of Section D or only complete items 51 and 57-60.
50. RECIPROCITY VERIFIED BACKGROUND INVESTIGATION COMPLETED
Yes No Not applicable 54. TYPE OF INVESTIGATION
51. TYPE OF BACKGROUND INVESTIGATION TO COMPLETE
Tier 1 Tier 2 Tier 2S Tier 2R 54a. DATE OF FAVORABLE ADJUDICATION

Tier 2RS Tier 3 Tier 3R Tier 4

Tier 4R Tier 5 Tier 5R 55. COMMENTS

Other (please list)

51a. DATE eQIP SENT to OPM

REGISTRAR INFORMATION
56. NAME (Last, First, Middle)
52. FBI FINGERPRINT CHECK RESULTS RECEIVED (mm/dd/yyyy)

57. REGISTRAR HHS ID NUMBER

53. FAVORABLE RESULTS?
Yes No

I hereby Approve Disapprove issuance of an HHS ID Badge to the above-named Applicant. I hereby acknowledge that if I knowingly
provide or assist in the provision of false information, non-verifiable information, and/or I purposely omit information, I may be subject to disciplinary
action up to and including removal from the Federal service, and I may be subject to prosecution under applicable Federal criminal and civil statutes.

58. REGISTRAR SIGNATURE 59. DATE (mm/dd/yyyy)

E. HHS ID BADGE DETAILS (To be completed by Issuer, after Section D has been completed)
60. NAME ON ID BADGE
ISSUER INFORMATION

63. NAME (Last, First, Middle)

61. ID BADGE NUMBER

64. ISSUER HHS ID NUMBER

62. ID BADGE EXPIRATION DATE (mm/dd/yyyy)

I confirm that the (1) ID Badge Request received from the Sponsor is valid, and (2) approval notification received from the
Registrar is valid.
I have verified that the individual collecting the ID Badge is the Applicant and have issued the ID Badge to the Applicant.
I have mailed the ID Badge and this form to
in Remote Office on this date (mm/dd/yyyy) .
I hereby acknowledge that if I knowingly provide or assist in the provision of false information, non-verifiable information, and/ or I purposely omit
information, I may be subject to disciplinary action up to and including removal from the Federal service, and I may be subject to prosecution under
applicable Federal criminal and civil statutes.

65. ISSUER SIGNATURE 66. DATE (mm/dd/yyyy)

FOR REMOTE ISSUERS I have verified that the individual collecting the ID Badge is the Applicant and have
issued the ID Badge to the Applicant.
67. REMOTE ISSUER NAME (Last, First, Middle) 68. REMOTE ISSUER ID

69. REMOTE ISSUER SIGNATURE 70. DATE (mm/dd/yyyy)

F. APPLICANT ACKNOWLEDGEMENT (To be completed by Issuer, after Section E has been completed)
I have read and understand the Privacy Act Statement and HHS ID Badge Rules that were given to me. I accept the HHS ID Badge and agree to
abide by the HHS ID Badge Rules.
71. APPLICANT SIGNATURE 72. DATE (mm/dd/yyyy)

HHS-745 (09/18) PAGE 3 of 5

 PRIVACY ACT STATEMENT (Applicant Copy)
The information on this form is collected by the Department of Health and Human Services (HHS) to issue you an identfication
badge called the HHS ID Badge. The purpose of the ID Badge is to help ensure the safety and security of government buildings,
the people who work in them, and government computer systems. When you use your ID Badge an ID Badge system will verify
that you are authorized to use government facilities. The system also will track and control the ID Badges that are issued. The
authority to collect this information is 5 U.S.C. § 301; Presidential Memorandum on Upgrading Security at Federal Facilities, June
28, 1995; and Homeland Security Presidential Directive 12, August 27, 2004. The authority to request your Social Security
number is Executive Order 9397. The disclosure of your Social Security number is voluntary, but it will assist in verifying your
identity to process this application.
The information on this form may be disclosed only with your written consent, except where permitted by the Privacy Act. The
disclosures permitted by the Privacy Act include disclosure to: the Department of Justice, a court, or other government officials
when the records are relevant and necessary to a law suit; the appropriate public authority (Federal, foreign, State, local, tribal, or
otherwise) to enforce, investigate, or prosecute, when a record indicates a violation of law or regulation; a Member of Congress or
congressional staff member at your written request; the National Archives and Records Administration for records management
inspections; authorized Federal contractors, grantees, or volunteers who need access to the records to do agency work and
who have agreed to comply with the Privacy Act; any source that has records an agency needs to decide whether to retain an
employee, continue a security clearance, or agree to a contract, grant, license or benefit; Federal, State, or local agencies, entities,
individuals, or foreign governments to enable an intelligence agency to carry out its responsibilities; the Office of Management and
Budget to evaluate private relief legislation; and to other Federal agencies to notify them when your ID Badge is no longer valid.

If you do not provide all of the requested information, we may deny you an ID Badge. Without an ID Badge, you will not have
access to certain Federal facilities or systems. If using an ID Badge is a condition of your employment, not providing the information
may prevent you from being able to work.

HHS-745 (09/18) PAGE 4 of 5

 DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) ID BADGE RULES (Applicant Copy)

The rules associated with the HHS ID Badge include but are not limited to

• Do not attempt to clone, modify, or obtain data from any HHS ID Badge.

• Protect and safeguard your ID Badge.

• If your ID Badge is lost or stolen, you must report the missing ID Badge within 24 hours of noting its disappearance. Your ID Badge
will be disabled and you will have to apply for a replacement.

• If you become aware of any violation of these requirements or suspect that your ID Badge may have been used by someone else,
immediately report that information to your agency’s ID Badge issuing authority.

• You must request a new ID Badge within 30 days in the event of any change which may affect the ability to determine that you are
the individual associated with the ID Badge (e.g., name change). You will provide documentation showing the reason for any such
change where applicable.

• As part of the HHS exit process, you are to return your ID Badge to the designated official at your agency on your last day of
employment at HHS or at the expiration of your authorized access to HHS facilities and/or IT systems.

• Do not attempt to assist others in gaining unauthorized access to Federal facilities or information. Accept responsibility for the
whereabouts and conduct of any and all persons whom you have signed in (i.e., authorized admittance) to HHS facilities. All
persons signed into HHS facilities are considered visitors. Only visitor badges will be issued.

• Do not disclose or lend your identification number and/or password to someone else to gain access to HHS IT systems. They are
for your use only and serve as your electronic signature. This means that you may be held responsible for the consequences of
unauthorized access or illegal transactions.

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