(09-99, rev.07-07)
Originating office completes items 1 - 6. Employee hand-carries form to organizations listed in Items 7-11. Form should reach the Office of Security and the Headquarters Servicing Human Resources (Personnel) office on or before the last day of active duty.
6A-211/FORS or
call x6-1522
1F-039/FORS
R-006/GTN
GB-172/FORS
E-072/GTN
1G-033, FORS
B-106/GTN
4E-084, FORS
F-133/GTN
CLEARANCE:
PROPERTY/EQUIPMENT/COMPUTER TERMINAL TURNED IN OR TRANSFERRED
RECORDS TRANSFERRED
GC LAW LIBRARY (6-4848)
KEYS TURNED IN (Collect)
AMERICAN EXPRESS AND VISA CREDIT CARD TURNED IN (Collect)
SAFE COMBINATIONS (Change as necessary)
SPECIAL ACCESS TERMINATION CONTACT 6-5085 TO VERIFY IF DEBRIEFING IS REQUIRED
TS DOCUMENTS CONTACT APPROPRIATE TOP SECRET CONTROL OFFICER OR (HSO)
SEET PROGRAM MANAGER (Room 4E-084) RECORDS LIAISON OFFICER (RLO)
Cleared by Date Cleared by Date
ENERGY INFORMATION ADMINSTRATION
HC - EMPLOYEE WORKLIFE CENTER
HC - OCCUPATIONAL HEALTH UNIT
IM - DIRECTORY/TELEPHONE CREDIT CARD
IM - USER-ID/ACCESS CONTROL
IM - SECURE VOICE TELEPHONE
MA - PARKING OFFICE ADMINISTRATIVE OFFICER DATE
WHEN NECESSARY
HEADQUARTERS' SECURITY OFFICER DATE
NNSA, SC, OIG -- see instructions
Items 7-10 - Employees hand carry this form to the offices listed. Note that Item 7 applies only to employees required to file Financial Disclosures (see below). Enter N/A in the "Cleared" box if Item 7 does not apply.
Item 11 should be the LAST clearance. Final clearance for NNSA, SC, and OIG employeegranted by their respective Human Resource office. (NNSA - GB-157/FORS; F-125/GTN ; SC -G-WIng/2nd floor/GTN; OIG-5D-031/FORS)
SF-278 is required for all separating employees that are paid at a rate of SES (or equivalent) or above and worked 60 days or
more in the preceding year.
Administrative Officer - If the employee has a financial or property obligation a copy of this form should be submitted to the PAyroll and Budget Execution Team by the separation date for salary offset. The Payroll team is located at CF-11 Room C-248 GTN or FAX (301) 903-3916
Secure Voice Telephone (STU111) - Keys
turned in to Headquarters Security Officer
(HSO)
American Express/Visa Credit Card - Cut
card in half and return to Administrative Officer
Subsidy for Energy Employee Transit (SEET) - Return fare media to SEET Program Manager Room 4E-084/FORS. Call 6-2452 to obtain financial obligation balance information
Transfer of Records - Transfer Federal Records to Person assuming responsibility or a Records Liaison Officer (RLO)
Items 6A - Originating office is required to
clear departing employee for each of these
items
Records Management - notify the Records Liaison Officer that custodainship of the Federal records has been transferred and identify the new custodian by name, telephone number, and physical location. For information/ assistance contact 301-903-0593 or
http://cio.energy.gov/records-management.htm
Item 6B - For employee action (as applicable) Parking Permits - Return to CG-031 Forrestal or E-078 Germantown
Items 1 - 4 is to be completed by the
originating office to which the person is
assigned, in most cases the Administrative
Officer
(09-99) (rev.07-07
GC Law Library - Call 6-4848 to obtain clearance
UPON COMPLETION RETURN THIS FORM TO THE
ADMINISTRATIVE OFFICER