HTML version of the Security Screening Certificate and Briefing Form

• Reference No.
• Departmental/Organization No.
• Office Use Only
  • File Number

Part A - To Be Completed By Security Office

• Surname:
• Full given names (no initials), underline usual name used:
• Department/Organization/Agency:
• Unit/Branch:

• Initial briefing or reactivation
• Change in security requirement
• Termination

Authorized Level of Individual

Reliability status / security clearance authorized is:

• Reliability Status
  • Level - I (CONFIDENTIAL)
  • Level - II (SECRET)
  • Level - III (TOP SECRET)
  • Other (specify):
• Site access:

I, the undersigned, as the authorized security official, do hereby certify that the above information has been verified and the requested level is granted.

• Signature:
• Date:

• Name and title of authorized security official:
• Office address:
• Telephone:
• Facsimile:

Part B - Briefing Summary

The individual named herein is authorized access to the level of information/assets indicated above when there is a work related need.

If an individual fails to safeguard, releases without appropriate authority or uses information/assets for unauthorized purposes, such action may constitute a contravention of the Security of Information Act, the Access to Information Act, the Privacy Act or other Acts of Parliament, a breach of the Government Security Policy or the Oath of Secrecy.These provisions apply both during and after service to the Government of Canada. Specific safeguards are identified in the Government Security Policy and Standards and in corresponding departmental or organizational policies which apply to classified and protected information/assets. These safeguards must be applied.

Classified or protected information/assets must be returned immediately to the appropriate institutional authority when notification is given that the person named herein no longer requires access to such information/assets.

Part C - Acknowledgement

I understand and agree to comply with the above statutory and administrative requirements.

• Signature of individual:
• Date:

Part D - Briefing Official

• Name and initials:
• Title:
• Signature:
• Date:

Privacy Act Statement

The purpose of this form is to provide a record of the initial and any subsequent security briefing of individuals who have been granted a reliability status, security clearance or site access pursuant to the Government Security Policy (GSP) of the Government of Canada and is protected by the provisions of the Privacy Act in institutions which are covered by the Privacy Act. The personal information collected is described in Standard PIB PSU 917 (Personnel Security Screening) which is used by all government agencies, except the Department of National Defence PIB DND/PPE 834 (Personnel Security Investigation File), RCMP PIB CMP PPU 065 (Security/Reliability Screening Records), CSIS PIB SIS PPE 815 (Employee Security), and PWGSC PIB PWGSC PPU 015 (Personnel Clearance and Reliability Records) used for Canadian Industry Personnel. Additionally, a copy of this form may be retained within PIB PSE 901(Employee Personnel Record) or other institution specific Employee Personnel Record Banks.

Security of Information Act, Part II of Bill C-36 Entitled the Anti-Terrorism Act

18. (1) Every person with a security clearance given by the Government of Canada commits an offence who, intentionally and without lawful authority, communicates, or agrees to communicate, to a foreign entity or to a terrorist group any information that is of a type that the Government of Canada is taking measures to safeguard.

(2) Every person who commits an offence under subsection (1) is guilty of an indictable offence and is liable to imprisonment for a term of not more than 2 years.

Instructions

1. This form is to be completed:
   1. upon issuance of Reliability Status or Security Clearance;
   2. following a change in the authorized level of the individual or the positions/contracts security requirement.

TBS/SCT 330-47 (Rev. 2006/02)