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Healthcare/Public Health Registration (Government)
Who should register?  Individuals currently employed by a government agency or affiliated with a government agency through an executed contract, who serve in a public health function, i.e. Public Health Officers, EMT, Paramedic, Health/Hospital Emergency Manager, Communicable/Infectious Disease, Behavioral Health & Recovery (addiction), Environmental Health. Non-government healthcare professionals should apply for NCRIC Private Sector Membership 
(Please, no personal e-mail addresses) 

CONTACT INFORMATION
(for registration purposes only)
First Name  *

Last Name *

Position/Title/Rank:  *

Phone Work: *

Mobile Phone: * (for 2FA Authentication)

E-mail:  * (must use agency/organization email address)


WEBSITE ACCESS
Password: * 8 chars 1 special 1 numeric
Create a password for site / modify contact information)


Do you have Security Clearance?:
Yes  No

Cleared Through:
FBI DOD DHS N/A
If cleared through other state below:


  

AGENCY / ORGANIZATION
Agency/Organization Name:  *

If your agency does not appear on the above list, complete the Full Agency Name below.
Other Agency/Organization Name:

Federal State Local  Military Other
Address: *

City: *

County: *

State:*
   Zip code:*

SUPERVISOR / EMPLOYMENT VERIFICATION CONTACT
Full Name*

Supervisor's Title*

Phone Work:* (###-###-####)

Supervisor's Email Address:*
(Organization email addresses only)

Confirm Your Supervisor's Email Address:*
 

 

All registration information is considered strictly confidential.
 

I agree to the following terms and conditions:

NONDISCLOSURE TERMS & CONDITIONS AGREEMENT BETWEEN THE NORTHERN CALIFORNIA REGIONAL INTELLIGENCE CENTER (NCRIC) AND THE APPLICANT PERTAINING TO THE PROPER HANDLING OF "FOR OFFICIAL USE ONLY" (FOUO)" INFORMATION.

1. I hereby accept the obligations contained in this Agreement in consideration of my being granted access to FOUO information. As used in this agreement, FOUO information is marked or unmarked FOUO information, including oral communication, which is FOUO information under the standards of the NCRIC. I understand and accept that being granted access to FOUO information, special confidence and trust shall be placed in me by the NCRIC.

2. I hereby acknowledge that I have read the attached document, titled "Safeguarding Sensitive but Unclassified Information" and a copy has been provided to me, and that I have received a security indoctrination concerning the nature and protection of FOUO information, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

3. I have been advised that the unauthorized disclosure, unauthorized retention, or negligent handling of FOUO information by me could cause damage or irreparable injury to the NCRIC. I hereby agree that I will never divulge FOUO information to anyone unless: (a) I have officially verified that the recipient has been properly authorized by the NCRIC to receive it; or(b)I have been given prior authorization from the agency responsible for the information that such disclosure is permitted; or (c) the recipient has the "need to know" in order to perform their official duties. I understand that if I am uncertain about the classification status or handling control authority of information received from the NCRIC, I am required to confirm from an authorized NCRIC official that the information is FOUO before I may disclose it, except to a person as provided in (a) or (b) above.

4. I have been advised that any breach of this Agreement may result in the termination of my affiliation with the NCRIC.

5. I have read this agreement carefully and my questions, if any, have been answered.