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Department of Defense
Periodic Review Secretariat (PRS) at
U.S. Naval Base Guantanamo Bay, Cuba
As a candidate to become a member of the PRS, please complete the following questionnaire, and
provide it to the PRS Manpower Officer for review by PRS Director. Because of the sensitive
personal information requested, no copy will be retained on file outside of the PRS.
1. Name (Last, First MI): 2. Rank/Grade:
3. Date of Rank: 4. Selected for Promotion? Y/N: __________
5. Service: 6. Active, Reserve, or Guard: _____________
7. Total Active Federal Service (years/months): ______ 8. Designator/MOS:
9. Designator/MOS Description: ___________________________________________________
10. Date Current Tour Began: 11. Are you Retired Reserve? ___________
12. Security Clearance Level: 13. Date of clearance: ______
14. Military Awards / Decorations:
______________________________________________________________________________
15. Current Duty Position: 16. Unit:
_____ 17. Date of Birth: ___
18. SSN (need full SSN to verify clearance): ____________
19. Height/Weight: ________ 20. Sex/Race: ____ ___
21. Civilian Education. College/Vocational/Civilian Professional School to include date
graduated or dates attended (and number of years), school, location, degree/major: ____________
________________________________________________________________________
______________________________________________________________________________
22. Military Education. Dates attended, school/course title:

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23. Duty Assignments. Last four assignments, units, and dates of assignments:
24. Have you had any close friend or relative killed or wounded in Afghanistan or Iraq?
Y/N EXPLAIN.
25. Have you had any close relative or friend killed, wounded, or impacted by the events of
September 11, 2001? Y/N EXPLAIN.
26. Have you ever been in an assignment related to enemy prisoners of war or enemy
combatants? Y/N EXPLAIN.
27. Have you ever been a member of the Military Commission Privilege Team, Habeas Privilege
Team or any other unit involved with the screening of mail to, and from, Law of War detainees?
Y/N___________________________________________________________________________
______________________________________________________________________________
28. Is there any reason why you could not objectively advocate on behalf of Law of War
detainees? Y/N EXPLAIN.
__________________________
29. Is there any reason you could not objectively capture information that could assist the
Periodic Review Board (PRB) in making a decision to release, transfer, or continue detention of
Law of War detainees? Y/N EXPLAIN.
_____________

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30. Could the inadvertent release of your name as a participant in the Periodic Review Board
(PRB) process affect your ability to objectively participate in subsequent PRB proceedings?
Y/N EXPLAIN.
31. While assigned to PRS, we may need to deploy you to U.S. Naval Base Guantanamo Bay,
Cuba for extended periods of time, on short notice. Will this create any hardship for you and/or
your family? Y/N EXPLAIN.
32. Are you physically qualified for worldwide deployment?
Y/N EXPLAIN.
33. Are there any personal or professional issues that might prevent you from working a dynamic
schedule, potentially including a seven-day work week or working anytime within a 24-hour shift
(without notice)? Y/N EXPLAIN.
34. Are you currently the subject of an investigation by any military or civilian investigative or
law enforcement body? Y/N EXPLAIN.
35. Are you currently a party to any civilian or military legal proceeding?
Y/N EXPLAIN.

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36. Contact Information (e-mail address, work address, home address, work, cell, and home
phone numbers):
_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SIGNATURE OF MEMBER: DATE:
PRIVACY ACT WARNING
Information contained in this system is subject to the Privacy Act of 1974 (5 U.S.C.552A, as
amended). Personal information contained in this system may be used only by authorized persons
in the conduct of official business. Any individual responsible for unauthorized disclosure or
misuse of personal information may be subject to fines up to $5,000.
PRS SECURITY CLEARANCE REQUIREMENTS FOR NEW ARRIVALS
All personnel will possess a current SECRET Clearance. Most billets
require eligibility for TOP SECRET/SCI. Parent command Security
Manager / SSO’s are requested to provide the following information on
all inbound personnel.
A valid visit request – OPNAV Form 5521. Specific information to
include:
To: PRS, Arlington, VA
Specific Location to visit: PRS Operations Center
Duration of Visit: IAW TAD Orders
Purpose of Visit: TDY
Note: Level of Security Clearance should be validated with the
effective date of granted Clearance and the date and type of last
investigation. Keep in mind that Secret Clearances only last 10 years
from the last NAC investigation and TS and above clearances last only
five years from the last Single Scope Background Investigation Date.
Unit Security managers can contact PRS’s Security Manager, COMM (703)
601-5995, DSN PREFIX (329), FAX: (703) 601-1825.