NDU SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

PRIVACY ACT STATEMENT

AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act. PRINCIPAL PURPOSE: To record names, signatures, and Social 

Security Numbers for the purpose of validating the trustworthiness of Individuals requesting access to Department of Defense (DoD) systems and information. NOTE: 

Records will be maintained in soft and/or hard copy2. ROUTINE USES: None. DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the 

requested information may impede, delay or prevent further processing of this request.

TYPE OF REQUEST DATE (yyyymmdd)

[ ] INITIAL [ ] MODIFICATION [ ] DEACTIVATION [ ] USER ID: _______________

SYSTEM NAME (Platforms such as NDU Intranet, Google Cloud, Blackboard, Wireless Internet Gateway, etc.)

PART I – USER INFORMATION, CONSENT, AGREEMENT AND RESPONSIBILITIES (Completed by requester)

1. NAME (Last, First, Middle Initial) 2. RANK/TITLE

3. BUILDING # 4. OFFICE # 5. OFFICE PHONE # 6. Non-NDU PHONE #

7. POSITION TITLE 8. ORGANIZATION (NDU Affiliation) 9. NDU BADGE #

10. NDU PRIMARY E-MAIL ADDRESS 11. Non-NDU E-MAIL ADDRESS 12. BADGE EXPIRATION DATE

13. OFFICIAL MAILING ADDRESS 14. CITIZENSHIP 15. CAC USER

[ ] YES

[ ] NO (Skip to 17)

[ ] US Citizen

[ ] US Resident

[ ] Foreign National: __________________ CAC-EDIPI: _______________________

16. ACCOUNT TYPE 17. USER TYPE 18. MILITARY BRANCH (If not military skip to 20)

[ ] Faculty [ ] Military [ ] USAF [ ] USA

[ ] Student [ ] Civilian [ ] USN [ ] USMC

[ ] Volunteer

[ ] Staff 

[ ] Intern 

[ ] Summer Hire [ ] Contractor [ ] USCG [ ] Foreign Nation

19. PERSON REPLACED (If applicable) 20. ACTIVE DIRECTORY GROUP MEMBERSHIP

21. ADDITIONAL INFORMATION

22. IA TRAINING CERTIFICATION REQUIREMENTS (User must complete IA and PII training every 12 months)

23. NDU STATEMENT OF INFORMATION SYSTEM USE AND ACKNOWLEDGEMENT OF USER RESPONSIBILITIES

PART A: MANDATORY NOTICE & CONSENT FOR ALL DOD INFORMATION SYSTEM USER AGREEMENTS

By signing this document, you acknowledge and consent that when you access Department of Defense (DoD) information systems:

- You are accessing a U.S. Government (USG) information system (IS) (which includes any device attached to this information system) that is provided for U.S. Government authorized use only. You consent to the 

following conditions:

- The U.S. Government routinely intercepts and monitors communications on this information system for purposes including, but not limited to, penetration testing, communications security (COMSEC) monitoring, 

network operations and defense, personnel misconduct (PM), law enforcement (LE), and counterintelligence (CI) investigations.

- At any time, the U.S. Government may inspect and seize data stored on this information system. 

- Communications using, or data stored on, the given system(s) are not private, are subject to routine monitoring, interception, search, and may be disclosed or used for any U.S. Government-authorized purpose. - This 

information system includes security measures (e.g., authentication and access controls) to protect U.S. Government interests--not for your personal benefit or privacy.

- Notwithstanding the above, using an information system does not constitute consent to personnel misconduct, law enforcement, or counterintelligence investigative searching or monitoring of the content of privileged 

communications or data (including work product) that are related to personal representation or services by attorneys, psychotherapists, or clergy, and their assistants. Under these circumstances, such communications 

and work product are private and confidential, as further explained below:

- Nothing in this User Agreement shall be interpreted to limit the user's consent to, or in any other way restrict or affect, any U.S. Government actions for purposes of network administration, operation, protection, or 

defense, or for communications security. This includes all communications and data on an information system, regardless of any applicable privilege or confidentiality. 

The user consents to interception/capture and seizure of ALL communications and data for any authorized purpose (including personnel misconduct, law enforcement, or counterintelligence investigation). However, 

consent to interception/capture or seizure of communications and data is not consent to the use of privileged communications or data for personnel misconduct, law enforcement, or counterintelligence investigation 

against any party and does not negate any applicable privilege or confidentiality that otherwise applies.

- Whether any particular communication or data qualifies for the protection of a privilege, or is covered by a duty of confidentiality, is determined in accordance with established legal standards and DoD policy. Users are 

strongly encouraged to seek personal legal counsel on such matters prior to using an information system if the user intends to rely on the protection of a privilege or confidentiality.

- Users should take reasonable steps to identify such communications of data that the user asserts are protected by any such privilege or confidentiality. However, the user's identification or assertion of a privilege or 

confidentiality is not sufficient to create such protection where none exists under established legal standards and DoD policy.

NDU Form 2875 (2018-0105) FOR OFFICIAL USE ONLY Page 1 of 4 

22a. [ ] I have completed the Annual Information Awareness Training on the date indicated. 22b. DATE: ____________

22c. [ ] I have completed the JKO Personally Identifiable Information Training on the date indicated. 22d. DATE: ____________
- A user's failure to take reasonable steps to identify such communications or data as privileged or confidential does not waive the privilege or confidentiality if such protections otherwise exist under established 

legal standards and DoD policy. However, in such cases the U.S. Government is authorized to take reasonable actions to identify such communication or data as being subject to a privilege or confidentiality, and such 

actions do not negate any applicable privilege or confidentiality.

 - These conditions preserve the confidentiality of the communication or data, and the legal protections regarding the use and disclosure of privileged information, and thus such communications--and data are private and 

confidential. Further, the U.S. Government shall take all reasonable measures to protect the content of captured/seized privileged communications and data to ensure they are appropriately protected. - In cases when the 

user has consented to content searching or monitoring of communications or data for personnel misconduct, law enforcement, or counterintelligence investigative searching, (i.e., for all communications and data other than 

privileged communications or data that are related to personal representation or services by attorneys, psychotherapists, or clergy, and their assistants), the U.S. Government may, solely at its discretion and in accordance 

with DoD policy, elect to apply a privilege or other restriction on the U.S. Government's otherwise-authorized use or disclosure of such information.

 - All of the above conditions apply regardless of whether the access or use of an information system includes the display of a Notice and Consent Banner ("banner''), When a banner is used, the banner functions to remind 

the user of the conditions that are set forth in this User Agreement, regardless of whether the banner describes these conditions in full detail or provides a summary of such conditions, and regardless of whether the banner 

expressly references this User Agreement. 

PART B: NDU STATEMENT OF INFORMATION SYSTEM USE AND ACKNOWLEDGEMENT OF USER RESPONSIBILITIES FOR UNCLASSIFIED SYSTEMS

FOR AUTHORIZED ACCESS: 

I will use NDU Information Systems for official use and authorized purposes only in accordance with DoD 5500.7-R, Joint Ethics Regulation. I will not introduce or process data which the Information System is

specifically authorized to handle. I understand all information processed on NDU-controlled Information Systems is subject to monitoring; that includes email and web browsing. I may also be held both criminally and 

financially responsible for any damages that may occur to the network, systems, other electrical and non-electrical equipment, or computing devices, if my actions are determined to be deliberate, willful, or malicious. I 

understand the need to protect all passwords at the highest level of data they secure. I will not share my password(s) or account(s) information with other personnel not authorized to access the information system. 

I understand that I am responsible for all actions taken under my account(s) either as an authorized or privileged user. I will not attempt to "hack" the network, any connected Information Systems, or gain access to data 

which I am not authorized to access. 

I understand my responsibility to appropriately protect and label all output generated under my account (to include printed materials, USB devices, floppy disks, and downloaded hard disk files). 

I understand I must have the requisite security clearance and documented authorization (approved by my supervisor) of my need-to-know before accessing NDU/DoD information and information systems. I 

understand my responsibility to ensure Privacy Act, and other protected personal information (such as personally identifiable information) is protected while it is being processed or accessed. In computer 

environments outside the NDU physical data processing installations requiring access to NDU information and information systems (such as remote job entry stations, terminal stations, minicomputers, 

microprocessors, and similar activities), I know I must ensure appropriate protection of personal and sensitive data. 

I understand by signing this document I acknowledge and consent that when I access NDU and/or any DoD information system: 

I am accessing a U.S Government information system (as defined in CNSSI 4009) provided for U.S. Government-authorized use only; I understand I must complete designated IA training prior to initial system access. I 

understand that security protections may be utilized on NDU Information Systems to protect certain interests that are important to the Government. For example, passwords, access cards, encryption, or biometric access 

controls provide security for the benefit of the Government. These protections are not provided for my benefit or privacy and may be modified or eliminated at the Government's discretion. 

I understand that I am prohibited from the following:

 - Introducing classified information into an unclassified system or environment.

 - Accessing, storing, processing, displaying, distributing, transmitting, or viewing material that is abusive, harassing, defamatory, vulgar, pornographic, profane, racist, promotes hate crimes, or subversive in nature, or

 objectionable by nature to include; material that encourages criminal activity or violates any applicable local, state, Federal, national, or international law.

 - Violating the established security, release, and protection policies for information identified as Classified, Proprietary, Controlled Unclassified Information (CUI), For Official Use Only (FOUO), or Privacy Act- protected during

 the information handling states of storage, process, distribution or transmittal of such information.

 - Obtaining, installing, copying, pasting, transferring, or using software or other materials obtained in violation of the appropriate vendor's patent, copyright, trade secret, or license agreement; this includes peer-to-peer file

 sharing software or games.

 - Installing any unauthorized software (e.g., games, entertainment software) or hardware (e.g., sniffers). 

 - Knowingly writing, coding, compiling, storing, transmitting, or transferring malicious software code, to include viruses, logic bombs, worms, and macro viruses. 

 - Engaging in prohibited political activity. 

 - Using the system for personal financial gain such as advertising or solicitation of services or sale of personal property (e.g., eBay); or stock trading (i.e., issuing buy, hold and/or sell directions to an online broker).

 - Engaging in fundraising activities, either for profit or non-profit unless the activity is specifically approved by the Command (e.g.; Command social event fundraisers, charitable fundraisers, etc.). 

 - Gambling, wagering, or placing of any bets; writing, forwarding, or participating in chain letters. 

 - Posting personal web pages, using my personally-owned information technology (IT such as personal electronic devices (PEDs), personal data assistants (PDAs), laptops, thumb drives, etc.), or non-NDU-controlled

 information technology on NDU-controlled computing assets.

 - Any other actions prohibited by DoD 5500.7-R or any other DoD issuances. 

I will immediately report any indication of computer network intrusion, unexplained degradation, or interruption of network services, or the actual or possible compromise of data or file access controls to the appropriate 

Information Assurance (IA) Management or senior IA Technical Level representatives. I will not install, modify, or remove any hardware or software (i.e. freeware, shareware, security tools, etc.) without written permission 

and approval from the Information Assurance Manager (IAM) or senior IA Technical Level representative. I will not remove or destroy system audit, security, event, or any other logs without prior approval from the IAM or 

senior IA Technical Level representative. 

I will not introduce any unauthorized code, Trojan horse programs, malicious code, or viruses into NDU information systems or networks. 

I will not allow any user access to the network or any other connected system that is not cleared without prior approval or specific guidance of the IA Management. 

I will not use any NDU controlled information systems to violate software copyright by making illegal copies of software.

I agree to notify the organization that issued the account when access is no longer required.

[ ADDITIONAL PRIVACY ACT STATEMENT FOR NDU WIRELESS INTERNET GATEWAY USERS ]

AUTHORITY: 5 U.S.C. 301; 10 U.S.C. 131. PRINCIPAL PURPOSE(S): Identifies the NDU Wireless Internet Gateway user as receiving usage and security awareness training governing use of the Gateway and agreeing to use 

the Gateway in accordance with security and wireless policies. The information is used for identification purposes and to verify compliance with DoD requirements regarding accountability of information processing 

systems, and provides emergency contact information on the user in the event that the user’s access to the Gateway becomes compromised, or requires a reconfiguration due to security policy changes. ROUTINE 

USE(S): None. DISCLOSURE: Voluntary; however, failure to provide the requested information will result in denial of issuance of access to the NDU Wireless Internet Gateway.

NOTE: This form's Part I User Personal information is used to contact a (Wireless System) user in the event of a security incident or an emergency.

PART C: NDU WIRELESS GATEWAY USER ADDITIONAL STATEMENT OF INFORMATION SYSTEM USE AND ACKNOWLEDGEMENT OF USER RESPONSIBILITIES

The following preventive measure is required to ensure use of given device on the Wireless Gateway does not result in the release of DoD information to unauthorized persons: All devices connected to the NDU 

Wireless Network must be configured to require a passcode for device unlock. Sensitive data could be compromised if a device unlock passcode is not set up on a device connected to a DoD Network. These devices are 

particularly vulnerable because they are exposed to many potential adversaries when they are taken outside of the physical security perimeter of DoD facilities, and because they are easily concealed if stolen. DoD CIO 

Memorandum, "Policy on Use of DoD Information Systems Standard Consent Banner and User Agreement," 9 May 2008 requirements:

All above previous Part A user agreement statements herein apply to the NDU Wireless Gateway along with the following additional Acceptable Use requirements:

• Forfeiture - any personally-owned device involved in a CAT 1 security incident involving classified information shall be forfeited and will not be returned to the user.

• Users of any personally-owned mobile device on the Wireless Gateway shall ensure the given device is kept up-to-date with anti-virus definitions and security vulnerability updates.

 All NDU Government-issued devices authorized for use on the Wireless Gateway must be online and physically connected to the NDU intranet once a week, for at least 4 hours, between Wednesday and Friday to

 ensure necessary device patches and anti-virus updates get installed.

• Wireless Gateway users shall follow security policies which govern use of that connection; additionally, the following activites are prohibited: - 

Transmitting or downloading sensitive information (i.e., PII, HIPPA, FOUO, etc.), or classified information.

- Transmitting or downloading sexually explicit information, material that could be considered sexually harassing, or obscene language or material.

- Attempting to defeat any Wireless Gateway associated security systems.

- Viewing, changing or deleting files of another user without appropriate authorization or permission.

- Obtaining, installing, copying or using software in violation of the license agreement of the vendor.

- Unauthorized music and movie downloads (peer to peer activity), or improperly storing or processing copyrighted material.

- Transmitting or downloading offensive material, such as racist literature, and any activities for personal or commercial gain.

• Wireless Gateway users are required to report any Wireless Gateway system security incidents to the NDU Information Assurance Manager via the NDU IT Helpdesk.

ALL MUST READ AND SIGN: 

I understand that failure to comply with the requirements of this User Agreement will be reported and investigated. The results of the investigation may result in one or all of the following actions:

 - Immediate revocation of system access and/or user privileges 

 - Job counseling, admonishment 

 - Revocation of Security Clearance 

 - Uniform Code of Military Justice and/or criminal prosecution 

 - Disciplinary action, reassignment, discharge, or loss of employment 

23a. [ ] I HAVE READ, UNDERSTAND, AND WILL COMPLY WITH THE REQUIREMENTS SET FORTH IN THIS USER AGREEMENT.

IN THE EVENT OF CONFLICT, PART I TAKES PRECEDENCE OVER ABOVE PART II.

23b. SIGNATURE: 23c. DATE: 

NDU Form 2875 (2018-0105) FOR OFFICIAL USE ONLY Page 2 of 4 
PART II – ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT 

SPONSOR (If user is a contractor provide company name, contract # and contract expiration in 30a thru c) 

24. JUSTIFICATION FOR ACCESS

25. TYPE OF ACCESS REQUIRED [ ] AUTHORIZED [ ]PRIVILEGED

26. USER REQUIRES ACCESS TO

[ ] UNCLASSIFIED [ ] CLASSIFIED

(Specify Category): __________________

[ ] OTHER

(Specify Category): __________________

27. VERIFICATION OF NEED TO KNOW 28. ACCESS EXPIRATION DATE (If contractor use expiration date in 32)

I certify that this user requires access as requested [ ]

29. COMPANY NAME (If Contractor) 30. CONTRACT NUMBER (If Contractor) 31. CONTRACT EXPIRATION DATE

32. OPTIONAL INFORMATION (Additional Information)

33. SUPERVISOR NAME 33a. RANK/TITLE 33b. SIGNATURE 33c. DATE 

33d. ORGANIZATION & DEPARTMENT 33e. OFFICIAL MAILING ADDRESS 33f. PHONE 

34. IS OWNER OR APPOINTEE NAME 34a. RANK/TITLE 34b. SIGNATURE 34c. DATE 

34d. ORGANIZATION & DEPARTMENT 34e. OFFICIAL MAILING ADDRESS 34f. PHONE 

35. IAO OR APPOINTEE NAME 35a. RANK/TITLE 35b. SIGNATURE 35c. DATE 

35d. ORGANIZATION & DEPARTMENT 35e. OFFICIAL MAILING ADDRESS 35f. PHONE 

PART III – SECURITY MANAGER VALIDATES BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION

36. TYPE OF INVESTIGATION 37. DATE OF INVESTIGATION 38. CLEARANCE LEVEL

39. IT LEVEL DESIGNATION [ ] LEVEL I [ ] LEVEL II [ ] LEVEL III

40. SECURITY MANAGER NAME 40a. RANK/TITLE 40b. SIGNATURE 40c. DATE 

40d. ORGANIZATION & DEPARTMENT 40e. OFFICIAL MAILING ADDRESS 40f. PHONE 

NDU Form 2875 (2018-0105) FOR OFFICIAL USE ONLY Page 3 of 4 
INSTRUCTIONS

TYPE OF REQUEST: Completed by user.

TYPE OF REQUEST: Indicate user request type required.

DATE: Enter authorization request date. 

SYSTEM NAME: Enter name of system(s) user requires access.

PART I: Completed by user.

(1) Name. User last name, first name, and middle initial. 

(2) Rank/Title. User Rank or Title. 

(3) Building #. User's NDU office building #. 

(4) Office #. User's NDU office room #. 

(5) Office Phone #. User's NDU office phone #. 

(6) Non-NDU Phone #. Typically user's personal or home agency phone #. 

(7) Position Title. User's civilian, military or contractor job title. 

(8) Organization. User's NDU unit affiliation (such as iCollege, JFSC, etc.). 

(9) Badge #. User's assigned NDU or JFSC badge #. 

(10) Primary Email. User's NDU primary e-mail address. 

(11) Non-NDU Email. Typically user's personal or home agency e-mail.

(12) Badge Expiration. Date the user badge expires. 

(13) Official Mailing Address. User's official mailing address. 

(14) Citizenship. Select appropriate box; if FN, indicate nation. 

(15) CAC User. Select appropriate box; if "Yes", indicate the EDIPI #. The

user Social Security Number (SSN) is not the EDIPI; do not use user SSN.

(16) Account Type. Select appropriate box.

(17) User Type. Select appropriate box.

(18) Military Branch. Select appropriate box. 

(19) Person Replaced. Enter name of person user is replacing (if applicable) 

to help ensure identical user rights and permissions.

(20) Active Directory Group Membership. Defines access to NDU resources. 

Contact your local Information Management Officer, Supervisor, Information 

Owner or Government Sponsor. 

(21) Additional Information.

(22) IA Training and Awareness Certification Requirements. User indicates 

completion of required Annual Information Awareness Training and the date. 

(23) User Agreement & Signature. User must sign NDU 2875 with the 

understanding that they are responsible and accountable for their 

password(s) and system(s) access.

PART II: Completed and endorsed by user's supervisor or

Government Sponsor. 

(24) Justification for Access. A brief statement is required to 

justify establishment of an initial USER ID. Provide appropriate 

information if the USER ID or access to the current USER ID is modified. 

(25) Type of Access Required: Select appropriate box. The “Authorized” 

category will be used for individual with normal access. The “Privileged” 

category will be used for those with privilege to amend or change system 

configuration, parameters, or settings. 

(26) User Requires Access To: Select appropriate box. If applicable, 

specify category. 

(27) Verification of Need to Know. To verify user requires requested 

access.

(28) Expiration Date for Access. The user must specify expiration date. If

user is a contractor, then field 32 and 32c are one and the same. 

(29) Company Name. If contractor, type the name if his/her company. 

(30) Contract Number. If contractor, type his/her company’s contract 

number.

(31) Contract Expiration. If contractor, type the contract’s expiration date. 

(32) Additional Information. As required.

(33) Supervisor Name. Enter supervisor or representative name to indicate 

form data has been verified and requested access is required.

(33a) Rank/Title. Rank or Title of the user’s supervisor or representative. 

(33b) Signature. Supervisor's signature is required by the endorser or his/her 

representative. 

(33c) Date. Date supervisor signs the form.

(33d) Organization & Department. Supervisor's organization and department. 

(33e) Official e-mail Address. Supervisor's e-mail address. 

(33f) Phone. Supervisor's phone #.

(34) Information System Owner or Appointee Name. Enter IS owner name 

to indicate form data has been verified and requested access is required.

(34a) Rank/Title. IS owner Rank or Title. 

(34b) Signature. IS owner signature. 

(34c) Date. Date IS owner signs form. 

(34d) Organization & Department. IS owner organization and department. 

(34e) Official e-mail Address. IS owner e-mail address. 

(34f) Phone. IS owner phone #. 

(35) Information Assurance Officer (IAO) or Appointee Name. Enter IAO

name to indicate the form data has been verified and requested 

access is required. 

(35a) Rank/Title. IAO Rank or Title. 

(35b) Signature. IAO signature. 

(35c) Date. Date IAO signs form. 

(35d) Organization & Department. IAO organization and department. 

(35e) Official e-mail Address. IAO e-mail address. 

(35f) Phone. IAO phone #.

PART III: Completed by the Security Manager conducting

the Background Investigation or Clearance Certification.

(36) Type of Investigation. The user's last type of background investigation 

(i.e., NAC, NACI, or SSBI). 

(37) Date of Investigation. Date of last investigation. 

(38) Clearance Level. The user's current security clearance level (Secret or 

Top Secret). 

(39) IT Level Designation. Select the user's IT designation (Level I, Level II, or 

Level III) if known. 

(40) Security Manager Name. Enter Security Manager or representative

name to indicate above clearance and investigation data has been verified.

(40a) Rank/Title. Rank or Title of the Security Manager or representative. 

(40b) Signature. Security Manager or representative’s signature. 

(40c) Date. Date Security Manager signs the form.

(40d) Organization & Department. Security Manager's organization and 

department.

(40e) Official e-mail Address. Security Manager 's e-mail address. 

(40f) Phone. Security Manager's phone #.

FORM DISPOSITION

TRANSMISSION: Form may be electronically transmitted, faxed, or mailed. 

Adding a password to this form makes it a minimum of "FOR OFFICIAL 

USE ONLY" and must be protected as such. 

FILING: Form is purposed to use digital signatures. Digitally signed forms must 

be stored electronically to retain non-repudiation of electronic signature. If 

pen and ink signature must be applied, original signed form must be retained. 

Retention of this form shall be IAW DOD and NDU's Record Management 

regulations and policies. Form may be maintained by the user's Information 

Assurance Officer and/or Security Manager. Completed forms contain 

Personal Identifiable Information (PII) and must be protected as such. 

NDU Form 2875 (2018-0105) FOR OFFICIAL USE ONLY Page 4 of 4