DD Form 2962 Personnel Security System Access Request (Pssar) - Defense Manpower Data Center (Dmdc) - Defense Information System for Security (Diss) Access

DD Form 2962 is a U.S. Department of Defense form also known as the "Personnel Security System Access Request (pssar) - Defense Manpower Data Center (dmdc) - Defense Information System For Security (diss) Access". The latest edition of the form was released in December 1, 2016 and is available for digital filing.

Download a PDF version of the DD Form 2962 down below or find it on U.S. Department of Defense Forms website.

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NAME (Last, First, and Middle Initial)
PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR)
OMB No. 0704-0542
DEFENSE MANPOWER DATA CENTER (DMDC)
OMB approval expires
September 30, 2018
DEFENSE INFORMATION SYSTEM FOR SECURITY (DISS) ACCESS
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the
burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directive Division, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0542). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. Return completed form to the appropriate Account Manager or DMDC Contact Center, as indicated in the
instructions.
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 12829, National Industrial Security Program; E.O. 10450, Security Requirements for Government Employment; E.O. 10865, Safeguarding Classified Information
Within Industry; (DoDI) 1400.25, Volume 731, DoD Civilian Personnel Management System: Suitability and Fitness Adjudication for Civilian Employees; DoD 5200.2-R, Department of
Defense Personnel Security Program; DoDI 5200.02, DoD Personnel Security Program (PSP); DoDD 5220.6, Defense Industrial Personnel Security Clearance Review Program; DoDI
5220.22, National Industrial Security Program (NISP); DoDI 5200.46, DoD Investigative and Adjudicative Guidance for Issuing the Common Access Card (CAC); Homeland Security
Presidential Directive (HSPD) 12, Policy for Common Identification Standard for Federal Employees and Contractors; and E.O. 9397 (SSN), as amended.
PURPOSE(S): To request the establishment of user roles and access and validate the trustworthiness of individuals seeking access to Defense Central Index of Investigations (DCII),
Secure Web Fingerprint Transmission (SWFT), or DoD Defense Information System for Security (DISS), (Case Adjudication Tracking System (CATS) or Joint Verification System (JVS)).
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. See the applicable System of Records Notice (DMDC
24 DoD, Defense Information System for Security (DISS)) for the applicable routine uses which may be found at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/799795/dmdc-24-dod/
DISCLOSURE: Voluntary. However failure to provide the requested information may impede, delay, or prevent further processing of your request. The Social Security Number is used
to verify the trustworthiness status in DISS.
DATE (YYYYMMDD)
TYPE OF REQUEST (REQUIRED)
USER ID (EXISTING ACCOUNTS)
INITIAL
MODIFICATION
DEACTIVATE
PART 1 - PERSONAL INFORMATION
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. ORGANIZATION
3. OFFICE SYMBOL/DEPARTMENT
4. PHONE (DSN or COMMERCIAL)
6. JOB TITLE AND GRADE/RANK
5. OFFICIAL E-MAIL ADDRESS
7. OFFICIAL MAILING ADDRESS
9. DATE OF BIRTH (YYYYMMDD)
8. CITIZENSHIP
10. PLACE OF BIRTH (CITY & STATE/COUNTRY)
11. SOCIAL SECURITY NUMBER
12. CAGE CODE (CTR ONLY)
13.
DESIGNATION OF APPLICANT
MILITARY
DoD CIVILIAN
INDUSTRY
NON-DoD
PART 2 - APPLICATIONS
14. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (GOVERNMENT ONLY)
a. DCII AGENCY CODE
DCII AGENCY ACRONYM
OR
b. USER PERMISSIONS:
QUERY (SEARCH)
ADD
UPDATE
DELETE
AGENCY ADMINISTRATOR
EXECUTIVE ADMINISTRATOR
FILE DEMAND (PROVIDE ACCREDITATION CODE:)
FILE DEMAND PRINT
ROOT ADMINISTRATOR
15. SECURE WEB FINGERPRINT TRANSMISSION (SWFT)
a. PERMISSIONS - FINGERPRINT SUBMISSION:
USER
MULTI-SITE UPLOADER
SITE ADMINISTRATOR
ORGANIZATION/COMPANY ADMINISTRATOR
b. PERMISSIONS - FINGERPRINT ENROLLMENT:
ENROLLER
TRANSACTION VIEWER
ENROLLER SITE ADMINISTRATOR
ENROLLER GROUP ADMINISTRATOR
c. ADDITIONAL CAGE/ORGANIZATION CODE(S):
OTHER
Designer 11
DD FORM 2962, DEC 2016
Page 1 of 4
PREVIOUS EDITION IS OBSOLETE.
NAME (Last, First, and Middle Initial)
PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR)
OMB No. 0704-0542
DEFENSE MANPOWER DATA CENTER (DMDC)
OMB approval expires
September 30, 2018
DEFENSE INFORMATION SYSTEM FOR SECURITY (DISS) ACCESS
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the
burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directive Division, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0542). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. Return completed form to the appropriate Account Manager or DMDC Contact Center, as indicated in the
instructions.
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 12829, National Industrial Security Program; E.O. 10450, Security Requirements for Government Employment; E.O. 10865, Safeguarding Classified Information
Within Industry; (DoDI) 1400.25, Volume 731, DoD Civilian Personnel Management System: Suitability and Fitness Adjudication for Civilian Employees; DoD 5200.2-R, Department of
Defense Personnel Security Program; DoDI 5200.02, DoD Personnel Security Program (PSP); DoDD 5220.6, Defense Industrial Personnel Security Clearance Review Program; DoDI
5220.22, National Industrial Security Program (NISP); DoDI 5200.46, DoD Investigative and Adjudicative Guidance for Issuing the Common Access Card (CAC); Homeland Security
Presidential Directive (HSPD) 12, Policy for Common Identification Standard for Federal Employees and Contractors; and E.O. 9397 (SSN), as amended.
PURPOSE(S): To request the establishment of user roles and access and validate the trustworthiness of individuals seeking access to Defense Central Index of Investigations (DCII),
Secure Web Fingerprint Transmission (SWFT), or DoD Defense Information System for Security (DISS), (Case Adjudication Tracking System (CATS) or Joint Verification System (JVS)).
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. See the applicable System of Records Notice (DMDC
24 DoD, Defense Information System for Security (DISS)) for the applicable routine uses which may be found at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/799795/dmdc-24-dod/
DISCLOSURE: Voluntary. However failure to provide the requested information may impede, delay, or prevent further processing of your request. The Social Security Number is used
to verify the trustworthiness status in DISS.
DATE (YYYYMMDD)
TYPE OF REQUEST (REQUIRED)
USER ID (EXISTING ACCOUNTS)
INITIAL
MODIFICATION
DEACTIVATE
PART 1 - PERSONAL INFORMATION
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. ORGANIZATION
3. OFFICE SYMBOL/DEPARTMENT
4. PHONE (DSN or COMMERCIAL)
6. JOB TITLE AND GRADE/RANK
5. OFFICIAL E-MAIL ADDRESS
7. OFFICIAL MAILING ADDRESS
9. DATE OF BIRTH (YYYYMMDD)
8. CITIZENSHIP
10. PLACE OF BIRTH (CITY & STATE/COUNTRY)
11. SOCIAL SECURITY NUMBER
12. CAGE CODE (CTR ONLY)
13.
DESIGNATION OF APPLICANT
MILITARY
DoD CIVILIAN
INDUSTRY
NON-DoD
PART 2 - APPLICATIONS
14. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (GOVERNMENT ONLY)
a. DCII AGENCY CODE
DCII AGENCY ACRONYM
OR
b. USER PERMISSIONS:
QUERY (SEARCH)
ADD
UPDATE
DELETE
AGENCY ADMINISTRATOR
EXECUTIVE ADMINISTRATOR
FILE DEMAND (PROVIDE ACCREDITATION CODE:)
FILE DEMAND PRINT
ROOT ADMINISTRATOR
15. SECURE WEB FINGERPRINT TRANSMISSION (SWFT)
a. PERMISSIONS - FINGERPRINT SUBMISSION:
USER
MULTI-SITE UPLOADER
SITE ADMINISTRATOR
ORGANIZATION/COMPANY ADMINISTRATOR
b. PERMISSIONS - FINGERPRINT ENROLLMENT:
ENROLLER
TRANSACTION VIEWER
ENROLLER SITE ADMINISTRATOR
ENROLLER GROUP ADMINISTRATOR
c. ADDITIONAL CAGE/ORGANIZATION CODE(S):
OTHER
Designer 11
DD FORM 2962, DEC 2016
Page 1 of 4
PREVIOUS EDITION IS OBSOLETE.
NAME (Last, First, and Middle Initial)
16. DEFENSE INFORMATION SYSTEM FOR SECURITY - JOINT VERIFICATION SYSTEM (DISS-JVS)
a. SMO NAME:
ORGANIZATION/AGENCY CODE:
b. ROLE REQUESTED AND OPTIONAL PERMISSIONS (MARK ALL THAT APPLY):
SECURITY OFFICER
SECURITY OFFICER ADMIN
SECURITY MANAGER
GRANT INTERIM ELIGIBILITY
UPDATE SUBJECT INFORMATION
SUSPEND ACCESS
MANAGE POLYGRAPH
OVERRIDE INVESTIGATION
GRANT/REMOVE NON-SCI
MANAGE TASKS
VIEW SCI ACCESS
REQUEST
ACCESS
ESTABLISH/REMOVE SUBJECT
MANAGE POLYGRAPH
MANAGE POLYGRAPH
MANAGE SCI ACCESS
ACCESS
VIEW SCI ACCESS
CREATE/VIEW/MODIFY VISIT
VIEW SCI ACCESS
COMPONENT ADJUDICATOR
MANAGE FOREIGN
GRANT INTERIM
MANAGE SCI ACCESS
MANAGE SCI ACCESS
RELATIONSHIPS
ELIGIBILITY
OVERRIDE
MANAGE REPORTS
MANAGE FOREIGN TRAVEL
MANAGE REPORTS
INVESTIGATION
REQUEST
GRANT INTERIM ELIGIBILITY
SUPERVISORY TASKS
VIEW SMO NOTIFICATIONS
MANAGE REPORTS
GENERATE AD HOC/PRE-DEFINED REPORTS
SUPERVISORY TASKS
INITIATE ADJUDICATION
ADJUDICATION
REQUEST
INITIATE/REVIEW/OVERRIDE
INVESTIGATION REQUEST
HUMAN RESOURCE MANAGER
SECURITY OFFICER VISIT ADMIN
HIERARCHY MANAGER
PHYSICAL ACCESS CONTROL
VIEW SUBJECT INFORMATION
VIEW SCI ACCESS
GENERATE AD HOC/PRE-
MANAGE SCI DISS
VIEW SCI ACCESS
DEFINED REPORTS
USER
ESTABLISH/REMOVE SUBJECT RELATIONSHIP
ACCOUNT MANAGER
GENERATE AD HOC/PRE-DEFINED REPORTS
VIEW SCI ACCESS
MANAGE SCI DISS
USER
17. DEFENSE INFORMATION SYSTEM FOR SECURITY - CASE ADJUDICATION TRACKING SYSTEM (DISS - CATS)
ORGANIZATION:
DIVISION:
BRANCH:
TEAM:
a. USER ROLE:
b. ROLE REQUESTED:
EXECUTIVE CHIEF
ADJUDICATOR
PE SCREENER
PROCESS TEAM
HELP DESK
INDUSTRY PROCESS
DIVISION CHIEF
TRAINEE
GENERAL COUNSEL
TEAM
BRANCH CHIEF
IT SCREENER 1
OPM LIAISON
QUALITY CONTROL
TEAM CHIEF
IT SCREENER 2
METRICS
ADMINISTRATOR
c. LIST ANY ELEVATED PERMISSIONS:
Designer 11
DD FORM 2962, DEC 2016
Page 2 of 4
PREVIOUS EDITION IS OBSOLETE.
NAME (Last, First, and Middle Initial)
PART 3 - TRAINING (I have completed and attached training certificates for:)
18.
CYBER AWARENESS TRAINING
DATE (YYYYMMDD)
19.
PERSONALLY IDENTIFIABLE INFORMATION TRAINING
DATE (YYYYMMDD)
PART 4 - APPLICANT'S CERTIFICATION
I hereby certify that I understand that by signing this personnel security system access request, I am solely responsible for the use and protection of the account
that I will be provided. I also understand that I am not authorized to share my account or logon credentials with any other individuals. I will utilize all tools and
applications in accordance with the account management policy and security policy, as well as all applicable U.S. laws and DoD regulations. I understand that if I
violate any account management policy, security policy, U.S. laws or DoD regulations, my account will immediately be terminated, I will no longer be responsible
for an account, and may be subject to criminal charges and penalties.
20. APPLICANT'S SIGNATURE
21. DATE (YYYYMMDD)
PART 5 - NOMINATING OFFICIAL'S CERTIFICATION
22. OPTIONAL INFORMATION (Add details for multiple SMOs required):
23. I certify that the above named individual meets the requirements for access, has the appropriate need-to-know, and if applicable, meets the
requirements for account management privileges. I am also aware that I am responsible for ensuring this individual will follow all account
policies, security policies, and all applicable DoD regulations and U.S. laws. Furthermore, I certify that the named applicant requires account
access as indicated above in order to perform assigned duties. These duties include:
24. NOMINATING OFFICIAL'S PRINTED NAME (Last, First, Middle Initial)
25. NOMINATING OFFICIAL'S TITLE
26. NOMINATING OFFICIAL'S TELEPHONE NUMBER 27. NOMINATING OFFICIAL'S SIGNATURE
28. NOMINATING OFFICIAL'S DATE
PART 6 - VALIDATING OFFICIAL'S VERIFICATION
I have verified that minimum investigative requirements for the above applicant have been met and the applicant has the necessary need-to-know to
access the personnel security systems requested.
29. ELIGIBILITY/ACCESS LEVEL:
30. TYPE OF INVESTIGATION:
31. ELIGIBILITY GRANTED DATE:
32. DATE INVESTIGATION COMPLETED:
33. ELIGIBILITY ISSUED BY:
34. INVESTIGATION CONDUCTED BY:
35. VALIDATING OFFICIAL'S NAME (Last, First, Middle Initial):
36. VALIDATING OFFICIAL'S SIGNATURE
37. VALIDATING OFFICIAL'S DATE
Designer 11
DD FORM 2962, DEC 2016
Page 3 of 4
PREVIOUS EDITION IS OBSOLETE.
NAME (Last, First, and Middle Initial)
PART 7 - PERSONNEL SECURITY SYSTEM ACCESS REQUEST (PSSAR) INSTRUCTIONS
Please see the respective System Access Request Procedures available from the DMDC PSA website for supplemental guidance on
completing and submitting this form.
Type of Request. Select "initial" for a new account, "modification" for a
Part 3 - Training.
change in privileges to an existing account, "deactivate" to remove all
18. - 19. Training Requirements. Mark in the box to certify training
access and disable an existing account. Complete the User ID field if
units completed and enter completion date for new accounts.
selecting "modification" or "deactivate."
Certificates must be submitted with PSSAR.
Date. Date request is submitted by applicant.
Part 4 - Applicant's Certification.
Part 1 - Personal Information.
20. Applicant's Signature. Signature of Applicant acknowledging DoD
1. Name. Last Name, First Name, Middle Initial of Applicant. If no
and system policies.
middle initial, enter "NMN."
21. Date. Date application signed by Applicant.
2. Organization. Employing organization of Applicant.
3. Office Symbol/Department. Employing office symbol or
Part 5 - Nominating Official's Certification.
department.
22. Optional Information. (Add details for multiple SMOs required):
4. Phone. Telephone number of Applicant. Enter DSN or Commercial
Include additional SMOs requested for applicant to have multiple
as appropriate.
affiliations.
5. Official E-mail Address. Official e-mail address of Applicant to be
23. Describe assigned duties.
used for account communication.
24. Nominating Official's Name. Last Name, First Name, and Middle
6. Job Title and Grade/Rank. Job title and pay grade or military rank
Initial. If no middle initial, enter "NMN."
of Applicant.
25. Nominating Official's Title. Title of Nominating Official.
7. Official Mailing Address. Official mailing address of Applicant.
26. Nominating Official's Telephone Number. (DSN or Commercial
8. Citizenship. Country of citizenship. If dual, enter both countries.
telephone number).
9. Date of Birth. Applicant's date of birth.
27. Nominating Official's Signature. The Nominating Official is the
10. Place of Birth. City and state, if born in the U.S. Otherwise, enter
individual who is authorizing that the Applicant should have the access
country and city.
requested. The Nominating Official may be a Key Management
11. Social Security Number. SSN of Applicant.
Personnel (KMP) listed in ISFD, Facility Security Officer, or Security
12. CAGE Code. Contractor only: CAGE code of Applicant.
Officer/Manager. For Industry Account Managers, the PSSAR must be
13. Designation of Applicant. Mark in the appropriate box for DoD
signed by the same KMP who signed the Appointment Letter. The
(e.g., military branches, DoD agencies, DoD contractor companies,
Nominating Official CANNOT be the same as the Applicant unless it is
non-DoD NISP partner and non-DoD affiliated).
a single person facility. NOTE: PSSARs submitted without the
Nominating Official's statement regarding duties and signature will not
Part 2 - Applications.
be processed.
14. DCII.
28. Nominating Official's Signature Date.
a. DCII Agency Code/DCII Agency Acronym. Complete if requesting
a DCII account. Provide the DCII Agency Code/DCII Agency Acronym
Part 6 - Validating Official's Verification.
if previously assigned by DCII Administrator and known. Otherwise,
Do not complete if self-nominating/validating.
contact DMDC Contact Center for assistance.
29. Eligibility/Access Level. Eligibility/Access level of Applicant. See
b. User Permissions. Requested User permissions are restricted to
applicable System Account Management Policies/Access Request
those granted to the Agency. Elevated permissions for the Agency
Procedures available from the respective DMDC PSA system website
must be requested from DCII Program Manager.
for minimum eligibility/access requirements.
15. SWFT.
30. Type of Investigation. Type of investigation completed for
a. Permissions - Fingerprint Submission. Applies to SWFT users.
Applicant.
Indicate the requested user permission(s) by marking the appropriate
31. Eligibility Granted Date. Date clearance granted, indicating if
box, or list in Item.
interim. If not final, state date of interim.
b. Permissions - Fingerprint Enrollment. Indicate the requested
32. Date Investigation Completed. Date investigation completed.
user permission(s) by marking the appropriate box. Only complete this
33. Eligibility Issued By. Organization that issued clearance.
section if you have or request a SWFT account (Government Only)
34. Investigation Conducted By. Investigating agency.
and are cleared to use the web-based fingerprint enrollment system.
35. Validating Official's Printed Name. Last Name, First Name, and
c. Additional CAGE Code(s). List only if different from box 12 of this
Middle Initial. If no middle initial, enter "NMN."
form. Cannot add CAGE or Organization code(s) to account with Multi-
36. Validating Official's Signature. The Validating Official signature
Site Uploader permission. The Nominating Official must have the
serves to affirm the information provided on the following lines (verify
authority to permit the use of the CAGE Code(s) by Applicant.
before signing): Eligibility/Access Level; Eligibility Issued By; Type of
16. DISS (JVS).
Investigation and Investigation Conducted By. For non-DoD
a. SMO Name or Organization/Agency Code. Security Management
government agency requests, the Chief of Security or designee must
Office name or Organization/Agency code.
complete this section.
b. Role Requested. Indicate the requested user role(s) by marking the
37. Validating Official's Signature Date. Date Investigation
appropriate box, along with any optional permissions requested.
Completed.
17. DISS (CATS).
a. User Role. Adjudication role.
b. Role Requested. Indicate the requested user role(s) by marking the
appropriate box.
c. List any Elevated Permission(s). This information is requested by
the user.
Designer 11
DD FORM 2962, DEC 2016
Page 4 of 4
PREVIOUS EDITION IS OBSOLETE.

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