ICR Attachment A: EPA Form 7740-6

Appendix A

Please read Privacy Act Statement and instructions on reverse before completing this form. OMB No. 2070-0075

United States Environmental Protection Agency
Washington, DC 20460

TSCA CBI Access Request, Agreement, and Approval
Section I. – Access Request
1. Name (Last, First, MI)

2. 9-Digit ID Number (e.g., SSN)

3. Telephone Number

4. Requestor (Agency/Office/Division/Branch)

5. Document Control Officer (DCO)

6. DCO Telephone Number

7. TSCA Sections for which access is
required. Check all that apply. Use blank

ALL

_____

- OR-

4 ___

5 ___

6 ___

8 ___

12 ___

13 ___

21 ___

space to request other sections not listed.
8. Justification for TSCA CBI access.

Other

Select appropriate code from instructions on
reverse side. (Check one for all that apply).

List Justification on reverse side
A

______

B

______

Section II. – Contract Information
9. Employer’s Name

10a. Employer’s Address

11. Contract Number

12. EPA Project Officer

C

-

______

D

______

Contractor Employees Only
10b. City

10c. ST

10d. Zipcode

13. EPA Project Officer Telephone

Section III. – OPPT Secure Storage Area Access – HQ Federal and HQ Contractor Employees Only
14. Check if EPA ID Badge is required.
Need Replacement

Yes (New)

No (List Present EPA ID Badge Number (____________________________)

15. List OPPT Restricted areas by Division to which physical access is required.
Home Division (24 hour access)

Other Divisions (6A.M. – 6P.M. only)

Access to CBIC Only

IMD (DCO and IMD Computer Rms.)

16. List OPPT areas by Division and Room Number for which Alarm Activation/Deactivation Authority is requested.

Section IV. – Confidentiality Agreement
I understand that I will have access to certain Confidential Business Information submitted under the Toxic Substances Control Act (TSCA, 15 USC
2601 et seq.). This access has been granted in accordance with my official duties relating to Environmental Protection Agency programs.
I understand that TSCA CBI may be used only in connection with my official duties and may not be disclosed except as authorized by TSCA and
Agency regulations. I have received a copy of, and understand the procedures set forth in, the TSCA CBI Protection Manual. I agree that I will treat
any TSCA CBI furnished to me as confidential and that I will follow these procedures.
I understand that under section 14(d) of TSCA (15 USC 2513(d)), I am liable for a possible fine of up to $5,000 and/or imprisonment for up to one year
if I willfully disclose TSCA CBI to any person not authorized to receive it. In addition, I understand that I may be subject to disciplinary action for
violation of this agreement with penalties ranging up to and including dismissal.
I understand that my obligation to protect TSCA CBI, which has been disclosed to me as part of my official job duties, continues after either termination
of my assignment or termination of my employment.
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any knowingly
false or misleading statement may be punishable by fine or imprisonment or both under applicable law.
17. Signature of Employee

18. Date

Section V. – Requesting Official Approval
19. TSCA CBI Security Briefing Date

20. Name and Signature of Requesting Official. (Immediate Supervisor – EPA Project Officer for
Contractors) As the immediate supervisor of (or the EPA Project Officer for) the above mentioned
employee, I certify he/she has successfully completed a TSCA CBI Security Briefing on the date shown.
Name

22. Date Received
DCO Code

Signature

23. Approved (TSCA Security Official Signature)
Barcode

Status Code

Alarm Zones

24. Approval Date
Data Entry Date and Initials
1.

EPA Form 7740-6 (Rev. 7-03). Replaces previous version of 7740-6 and 7740-6A.

21. Date

2.

Paperwork Reduction Act Notice
The public reporting burden for the collection of information is estimated to average 1.6 hours per response. This estimate includes time for
reviewing instructions, gathering and maintaining the needed data, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or any other aspect of this collection of information to the Chief, Policy and Guidance Branch, (2833T), US
Environmental Protection Agency, Ariel Rios Bldg., 1200 Pennsylvania Ave., NW, Washington DC 20460, and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, Washington, DC 20503, marked ATTENTION: Desk Officer for EPA.

Privacy Act Statement
Furnishing your Social Security Number is voluntary, but encouraged. The information on this form is used by EPA to maintain a record of
those persons cleared for access to TSCA Confidential Business Information (CBI) and to maintain the security of TSCA CBI.
Disclosure of information from this form may be made to the Office of Pollution Prevention and Toxics (OPPT) contractors in order to carry out
functions for EPA compatible with the purpose for which this information is collected; to other Federal agencies when they possess TSCA CBI and
need to verify clearance to EPA and EPA contractor employees for access; to the Department of Justice when related to litigation or anticipated
litigation involving the records or the subject matter of the records; to the appropriate Federal, State or local agency charged with enforcing a statute or
regulation, violation of which is indicated by a record in this system; where necessary, to a State, Federal or local agency maintaining information
pertinent to hiring, retention, or clearance of an employee, letting of a contract, or issuance of a grant or other magistrate or administrative tribunal; in
the course of litigation under TSC A; and to a member of Congress acting on behalf of an individual to whom records in this system pertain.

Instructions for Form Completion
Section I – To be completed by all
Section III – To be completed by HQ Federal
and HQ Contractor employees only
1. List Full Name
2. List 9-Digit ID (e.g., SSN)
3. List Telephone number of person in item 1
4. List Full Acronym of Requesting Office (i.e. EPA Office in which the
individual works or for contractor employees, the EPA Office with whom
the contract is with)
5. List the immediate Document Control Officer for the office in which the
individual works
6. List the telephone number of the Document Control Officer
7. Check the TSCA Sections for which access is requested or check ALL
if applicable
8. Circle the appropriate Access Justification Code
A. Employee is an EPA employee or EPA contractor employee whose
work assignments involve the New and/or Existing Chemical Programs of
TSCA. Hence access to the TSCA sections listed in item 7 of this form is
required in performance of his/her duties .
B. Employee is an EPA employee or EPA contractor employee whose
work entails the administration of computer systems housing TSCA CBI.
Hence access to the TSCA sections listed in
item 7 of this form is required.
C. Employee is an EPA employee or EPA contractor employee whose
work entails physical security or maintenance for TSCA CBI secure
storage areas. Although employee will not actually
work with any TSCA CBI materials, access to the TSCA sections listed in
item 7 of this form is required.
D. List Justification here

NOTE: These procedures apply only to employees requiring access to
OPPT Secure Storage areas. All others follow standard Agency
procedures.
14. Check either box a, b, c or (c&d) for EPA ID badge or Contractor
Building Pass. If box c is checked, write in badge number.
a. Yes - Check if new employee getting first EPA ID Badge. (New
programmed badge)
b. Need Replacement - Check if replacement ID Badge is needed
(replacement badge)
c. No - Existing badge needs programming. List ID Badge no.
15. Check and list OPPT secured areas for which access (via electronic
door control system) is required. List Division acronyms for the requested
areas.
Home Division - List Division in which employee works
Other Divisions - List other OPPT Divisions for which unrestricted
daytime access is requested
CBIC Only - To be checked for those who only need to access the
Confidential Business Information Center.
IMD Areas - Employees who need to regularly access the IMD Document
Control Office Suite should circle DC0 in the fourth block. Only IMD staff
and contractors who work in IMD computer rooms should circle IMD
Computer Rooms.
16. List OPPT areas by Division and Room numbers for which Alarm
Activation/Deactivation authority is requested. Generally, this is
employees home Division only.

Section II – To be completed by Contractor
Employees only

Section IV – To be completed by all

9. List Employer’s name
10a-d. List Employer’s address
11. List Contract number
12. List EPA Project Officer’s name
13. List EPA Project Officer’s telephone number

17. Employee Signature (must be original)
18. Signature Date

Section V – To be completed by all
19. Enter date employee attended TSCA CBI Security Briefing
20. Immediate Supervisor/EPA Project Officers name and sign.
21. Date of signature

Section VI – To be completed by OPPT Security