THIS AGREEMENT made in duplicate as of the day of , 2005-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I, where the Document Security Officer must fill out their name, title, and duty station. Ensure all details are accurate for proper documentation.
3. In the 'Nature of Violation' field, provide a comprehensive account of the incident. Include specifics such as time, date, place, and any classified documents involved. This section is crucial for understanding the context of the violation.
4. The Document Security Officer should then sign and date this section to validate the report before forwarding it.
5. Proceed to Section II where the violator must provide their statement and signature. This adds accountability and clarity to the report.
6. Once completed, ensure that both sections are executed in duplicate and forwarded to the GSA Security Officer within one full working day after reporting.

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