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APPENDIX B
REPORT OF UNFAVORABLE INFORMATION OR SUSPENSION OF ACCESS
1. All reports of unfavorable information or suspension of access will be submitted on DA Form 5248-R, or in comparable message format (see Figure B-1).
2. DA Form 5248-R will be submitted in one copy to:
Commander US Army Central Personnel Security Clearance Facility ATTN: PCC-FP-RR Fort George G. Meade, Maryland 20755
3. If an immediate response is required, commanders may submit a report by message in DA Form 5248-R format to: CDRCCF FT MEADE MD//PCC-FP-RR//.
4. DA Form 5248-R will be completed as follows:
a. Block #1 - Reporting Commander Block: Proper mailing address, including attention line, zip code/APO, and Unit Identification Code (UIC) will be entered. Unit's or parent unit's USAIRR Requester Account Control Number will be entered in appropriate block.
b. Block #2 - Supporting Special Security Officer: Self explanatory.
c. Block #3 - Unit Identification Code: Enter the Unit Identification Code (UIC). The UIC will be that of current command/unit or the individual's new command/unit to which clearance results will be sent.
d. Block #4 - SSN: Enter Social Security Number.
e. Block #5a - Name: Last name of individual will be entered in CAPITAL letters, followed by first name and middle name, for example, SMITH, John James. Indicate: (NMN) - No middle name; (IO) - initial only; (NMI) no middle initial, as appropriate.
f. Block #5b - Aliases and Former Names: Indicate all former names, maiden names, nicknames, names changed by court order, and other names which Subject is or has been known by. If none, so state.
g. Block #6a - Birth Date: Enter year, month, and day of birth, for example, 79 JUN 15.
h. Block #6b - Birth Place: Self explanatory.
i. Block #7a - Rank or Grade: Enter military or civilian rank/grade, for example, SSG, PVT, GS-11.
j. Block #7b - Status: Indicate individual's current military or civilian status, for example, active duty military, Army National Guard, US Army Reserve, Department of the Army Civilian.
k. Block #8a - Current clearance: Enter level of security clearance appearing on DA Form 873.
l. Block #8b - SCI: Self explanatory.
m. Block #8c - Date Granted: This is based on Block #8b.
n. Block #8d - Date/Type of Investigation: This is based on Block #8b.
o. Block #9 - Type of Report: Enter either "Initial" or "Follow-up", or "Final." All first reports will be Initial reports.
p. Block #10 - Unit Action Taken: Enter any action taken by the commander, for example, "Access Suspended," "Access Not Suspended," or, in the case of a deserter or incarcerated individual, "Clearance Revoked - DA Form 873 attached."
q. Block #11a - Basis of Report Offense/Allegation:
(1) What was the prohibited substance possessed or used by the Subject?
(2) How was Subject's possession or use detected?
(3) Did the Subject ever possess or use the prohibited substance prior to this incident? If so, when and how frequently?
(4) What amount of prohibited substance is involved?
(5) What was/is Subject's frequency of use? (Specify in numbers.)
(6) Attempt to determine Subject's future intent concerning the use of prohibitive substances.
(7) Provide list of other offenses to include punishment(s).
r. Block #11b - Action Taken: Explain in detail the circumstances surrounding the basis for the report. Provide all amplifying information to enable an adjudicator to make a thorough and comprehensive security evaluation.
s. Block #11c - Cdr's Recommendations: Indicate actions by commander to have the derogatory information resolved, for example, "AR 15-6 initiated," LI requested for DIS," "CID requested to investigate," or "Commander's inquiry in progress."
t. Block #12 - Enclosures: Indicate and attach a copy of all investigations/inquiries.
u. Block #13 - Date: Self explanatory.
v. Block #14 - Signature, Typed Name, Rank, Title: Include typed or printed name and official title of the individual authorized to sign the request.
w. Block #15 - Signature of Security Manager/Authorized Official: Self explanatory.
x. Block #16 - Status Code: See Item 7b.
Figure B-1.
