DOE Contractor Personnel Foreign Government Sponsored or Affiliated Activities Questionnaire and Attestation InfoEd Number: Lead PI Name: Department/ College: Individual’s Name: University status/ affiliation: (please select all that apply) Full-time faculty Graduate student Part-time faculty Undergraduate student Adjunct faculty Visiting Scholar Research Staf Visitor Laboratory staf Industry contractor Administrative staf Donor Postdoctoral candidate Other (please specify) Project Role: In order to support the U.S Department of Energy’s (“DOE”) scientific mission, national security, and the ongoing competitiveness of U.S research, the DOE issued order DOE Order 486.1A, “Foreign Government Sponsored or Affiliated Activities.” The Order prohibits DOE Contractor Personnel from participating in a Foreign Country of Risk Talent Recruitment Program and restricts Contractor Personnel from participating in many Foreign Country of Risk Other Foreign Government Sponsored or Affiliated Activities Additionally, the Order requires Contractors, Contracting Institutions, and subcontractors to report any potential prohibited or restricted activities to the Contractor and/or DOE This order applies to ALL individuals participating in research and development activities related to the cited project, regardless of the individual’s affiliation or relationship with the University, and regardless of whether the activity is paid/unpaid, or whether the activity is performed at the University or elsewhere This includes employees, staf members, visiting scientists, students, volunteers, and any other individual who participates in the cited project To facilitate required reporting under this Order and related contractual requirements, Clemson’s Office of Sponsored Programs (“OSP”) requires each individual participating in the cited DOE award to complete the following Questionnaire and Attestation Office of Sponsored Programs | Division of Research Clemson University 230 Kappa St Suite 200 | Clemson, SC 29634 | OFFICE OF SPONSORED PROGRAMS | PAGE Instructions: Please answer the following questions to the best of your ability If you have any questions about how to answer a specific question, please not hesitate to contact OSP at cuosp@clemson.edu Are you currently employed by a foreign entity? Yes No If yes, please specify: Entity Name Country Role Do you currently hold any type of position or appointment (including honorary appointments), regardless of whether the position paid or unpaid, with a foreign entity? Yes No If yes, please specify: Entity Name Country Type of Position or Appointment Do you participate (whether on a paid or unpaid basis) in any government, military, intelligence agency, or police entity? If not currently, have you participated in past service? If yes with respect to past services, please indicate any on-going obligation with the entity or entities Yes No If yes, please specify: Entity Name Country Current/Past Type of Position or Appointment Do you currently receive any type of benefit from a foreign entity? Examples of a benefit (monetary or otherwise) include research sponsorship (unfunded and funded), in-kind support, travel support, housing, provision of staf/equipment/materials/lab space/etc., honoraria, or other financial support? Yes No If yes, please specify: Entity Name Country Type of Position or Appointment www.clemson.edu/research OFFICE OF SPONSORED PROGRAMS | PAGE Do you currently participate in, or plan to participate in, any program or activity sponsored by a foreign government? Yes No If yes, please specify: Entity Name Country Name & Type of Program Attestation: As a condition of my participation in the cited Department of Energy project, I understand that I am required to report to OSP any activity, benefit, support, or engagement which is or may be determined to be a Foreign Country of Risk Talent Recruitment Program or Foreign Country of Risk Other Foreign Government Sponsored or Affiliated Activities I have answered the questions above to the best of my knowledge and ability Currently DOE defines a Foreign Country of Risk to include Iran, North Korea, China, and Russia I certify that to the best of my knowledge, I (select one): Do NOT participate in any activity or receive any type of benefit from any individual or entity that is a citizen of Iran, North Korea, China, and/or Russia; have fully disclosed my participation in activities, and/or receipt of any type of benefit from an individual or entity that is a citizen of Iran, North Korea, China, and/or Russia Should my answer to any question above change, or should I consider participating in any activity described above, I will notify OSP immediately I understand that failure to comply with these requirements will result in immediate temporary and/or permanent removal from the cited project and may result in other actions and penalties as may be reasonable or allowed by the University Name: Date: www.clemson.edu/research OFFICE OF SPONSORED PROGRAMS | PAGE www.clemson.edu/research ... support, or engagement which is or may be determined to be a Foreign Country of Risk Talent Recruitment Program or Foreign Country of Risk Other Foreign Government Sponsored or Affiliated Activities... OF SPONSORED PROGRAMS | PAGE Do you currently participate in, or plan to participate in, any program or activity sponsored by a foreign government? Yes No If yes, please specify: Entity Name Country... Activities I have answered the questions above to the best of my knowledge and ability Currently DOE defines a Foreign Country of Risk to include Iran, North Korea, China, and Russia I certify that to