**Individuals who hold SCI access have special responsibilities and
obligations to report to their security office any activities or conduct
that could conflict with their ability to protect classified
information. As such, you are required to report any personal foreign
travel to the Personnel & Document Security Division (PDSD) no later
than 14 calendar days in advance of travel. Please complete this form
and fax it to 202/720-1689 or email it to pdsd@usda.gov. Call PDSD at
202/720-7373 with any
questio**ns.![](media/image1.png){width="0.5416666666666666in"
height="0.75in"}

+------------------------------+---------------------------------------+
| ##                           |                                       |
+==============================+=======================================+
| ## Employee Information      |                                       |
+------------------------------+---------------------------------------+
| Full name:                   |                                       |
+------------------------------+---------------------------------------+
| Social Security Number (last |                                       |
| four digits):                |                                       |
+------------------------------+---------------------------------------+
| Current Citizenship(s) (to   |                                       |
| include Dual):               |                                       |
+------------------------------+---------------------------------------+
| Job Title:                   |                                       |
+------------------------------+---------------------------------------+
| Supervisor Name & Phone      |                                       |
| Number:                      |                                       |
+------------------------------+---------------------------------------+
| Agency:                      |                                       |
+------------------------------+---------------------------------------+
| Office Phone (unsecure):     |                                       |
+------------------------------+---------------------------------------+
| Mobile or cellular phone:    |                                       |
+------------------------------+---------------------------------------+
| Office Fax (unsecure):       |                                       |
+------------------------------+---------------------------------------+
| E-mail address:              |                                       |
+------------------------------+---------------------------------------+
| Date Submitted:              |                                       |
+------------------------------+---------------------------------------+
|                              |                                       |
+------------------------------+---------------------------------------+
| ## Travel I                  |                                       |
| nformation: Flight Itinerary |                                       |
|  Can Be Attached or Emailed  |                                       |
+------------------------------+---------------------------------------+
| Destination(s) City/Town:    |                                       |
+------------------------------+---------------------------------------+
| Destination(s) Country:      |                                       |
+------------------------------+---------------------------------------+
| Dates of Travel:             |                                       |
+------------------------------+---------------------------------------+
| Purpose for Travel:          |                                       |
+------------------------------+---------------------------------------+
| Names of Foreign National    |                                       |
| Contacts (if any) at your    |                                       |
| destination:                 |                                       |
+------------------------------+---------------------------------------+
| U.S. Passport number:        |                                       |
+------------------------------+---------------------------------------+
| If traveling on a foreign    |                                       |
| passport, state origin of    |                                       |
| passport and expiration      |                                       |
| date:                        |                                       |
+------------------------------+---------------------------------------+
|                              |                                       |
+------------------------------+---------------------------------------+
| ## For PDSD Use Only         |                                       |
+------------------------------+---------------------------------------+
| Date SCI access was          |                                       |
| approved:                    |                                       |
+------------------------------+---------------------------------------+
| Date SCI briefing was        |                                       |
| conducted:                   |                                       |
+------------------------------+---------------------------------------+
| Is Destination in a high     |                                       |
| threat zone? Yes or No       |                                       |
| (circle) Remarks:            |                                       |
|                              |                                       |
| If yes, did Subject receive  |                                       |
| a briefing? Yes or No        |                                       |
| (circle) Remarks:            |                                       |
+------------------------------+---------------------------------------+
| Name of Security Officer:    |                                       |
+------------------------------+---------------------------------------+
| **NOTICE**: The Privacy Act, |                                       |
| 5 U.S.C. 552a, requires that |                                       |
| federal agencies inform      |                                       |
| individuals at the time      |                                       |
| information is solicited     |                                       |
| from them, whether the       |                                       |
| disclosure is mandatory or   |                                       |
| voluntary, by what authority |                                       |
| such information is          |                                       |
| solicited, and what uses     |                                       |
| will be made of the          |                                       |
| information. You are hereby  |                                       |
| advised that authority for   |                                       |
| soliciting your Social       |                                       |
| Security Number (SSN) is     |                                       |
| Executive Order 9397. Your   |                                       |
| SSN is needed to keep        |                                       |
| records accurate because     |                                       |
| other people many have the   |                                       |
| same name and birth date.    |                                       |
| Your SSN will be used to     |                                       |
| identify you precisely when  |                                       |
| it is necessary to 1)        |                                       |
| certify that you have access |                                       |
| as indicated above. Although |                                       |
| disclosure of your SSN is    |                                       |
| not mandatory, your failure  |                                       |
| to do so may impede the      |                                       |
| processing of such           |                                       |
| certifications or            |                                       |
| determinations, or possibly  |                                       |
| result in the denial of your |                                       |
| being granted access to      |                                       |
| classified information.      |                                       |
+------------------------------+---------------------------------------+