Form DHS Form 10009 DHS Form 10009 Application for a Pre-Application Consultation

OMB Control No. 1640-0001
Expires: XX/XX/XXXX

REQUEST FOR A PRE-APPLICATION
CONSULTATION
A Pre-Application Consultation is a voluntary means through which OSAI provides
helpful guidance to potential applicants without requiring the completion and
submission of a full SAFETY Act Application. The Pre-Application Consultation is
intended to facilitate a process by which a potential applicant may provide DHS with
initial information regarding their Technology, so that DHS may, in turn, provide
potential applicants with guidance regarding the submission of an Application for
SAFETY Act Designation. The Pre-Application Consultation is also intended to
facilitate discussions regarding the SAFETY Act Application process. A PreApplication Consultation is not a prerequisite for submitting a full application for
SAFETY Act Designation.

(Pre-Application Consultation Request Form on following page)

Privacy Act Notice: DHS Authority to Collect This Information: 6 U.S.C. §§ 441–444 (the “SAFETY Act”) and 6 C.F.R. Part 25, 71 Fed. Reg.
33147, 33159. Principal Purposes: DHS collects telephone numbers, addresses, and other identifying information for the purpose of contacting
individuals seeking liability protections on issues related to the SAFETY ACT application process. Routine Uses and Sharing: In general, DHS will
not use this information for any purpose other than DHS personnel contacting the individual. However, DHS may release this information of an
individual on a case-by-case basis as described in the S&T SAFETY Act System of Records Notice (SORN), which can be found at:
www.dhs.gov/privacy. Disclosure: Submission of this information is voluntary and an individual may opt not to provide the requested information
or to provide only some of the information DHS requests. If an individual chooses to opt not to provide some or all of the requested information,
DHS may not be able to process the individual’s request.
PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 16400001 and this form will expire on XX/XX/XXXX. The estimated average time to complete this form is 1 hour per respondent. If you have any
comments regarding the burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC
20528.
DHS Form 10009 (10/06)

REQUEST FOR PRE-APPLICATION CONSULTATION

SELLER INFORMATION
P1. Seller Name: __________________________________________________________________
P1.1. Description of Seller. Please provide an overview of your company, including place of
incorporation and major affiliates or subsidiaries.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
P2. Non-proprietary Summary
P2.1. Name of your Technology: _____________________________________________
P2.2. Technology Description. Provide a non-proprietary overview of your Technology.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
P3. Detailed description of your Technology. In an attachment, please provide a detailed description
of your Technology and summarize your Technology’s qualifications for SAFETY Act
Designation.
P4. Past and anticipated sales. Note: It may be very important and could significantly expedite your
eventual application if your Technology has been acquired or utilized (or is subject to an ongoing
procurement) by the military, a Federal government agency, or a state, local or foreign
governmental entity.
Who has purchased, utilized or plans to purchase your Technology? (Choose all that apply.)
DHS Form 10009 (10/06)

Federal government (Agency: ________________________ Approximate Date:

)

State government (State: ____________________________ Approximate Date:

)

Local government (City/County:______________________ Approximate Date:

)

Commercial organization (Name: _____________________ Approximate Date:

)

Foreign government (Name: _________________________ Approximate Date:

)

Other (Name: ____________________________________ Approximate Date:

)

P5. Readiness for Sale. If your Technology has not previously been sold, provide an estimate of when
it will be available for sale.
Immediately available for sale
Expected to be available for sales within ____ months. (Fill in the blank.)
P6. Effectiveness
How do you know that your Technology is effective? What kinds of deployment information, test
results, independent studies, or other corroborative information could you provide as part of a full
Application to support the utility and effectiveness of your Technology? In an attachment,
provide a summary of the available information supporting the safety and effectiveness of your
Technology. Please indicate any deployments for military or governmental customers. It may be
very important and could significantly expedite your eventual application if your Technology has
been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal
government agency, or a state, local or foreign governmental entity.
P7. Liability Considerations
In an attachment, please identify the types of potential terrorist activity the Technology is intended
to counter. Please describe, to the extent practicable, the scope of damage, loss of life, or other
harm that could result from such terrorist activity. Please describe how the Technology has been
deployed to date or will be deployed in the future should SAFETY Act Designation be issued.

DHS Form 10009 (10/06)

Instructions for Completing Pre-Application Consultation Form:
Seller Information
Item P1. Seller Name
Enter the legal name of your organization.
Item P1.1. Please provide a succinct description of your company. Please include the place
of incorporation and any major affiliates or subsidiaries who will also be “sellers” of the
technology. If your company web site or other publication provides this information, you
may provide the web site locator or publication as a response to this question.

Item P2. Non-proprietary Summary
Item P2.1. Enter the name of your Technology.
Item P2.2. Please provide a succinct, non-proprietary description of your Technology.
When describing your Technology, focus on providing information that will help the
Department identify which subject matter technical expert evaluators would be best qualified
to review your Technology.
One important purpose of this item is to help the Department recognize potential conflicts
of interest and ensure that your application information is not disclosed to evaluators with
potential conflicts of interest. The Department is committed to protecting your sensitive
business data and may, upon request, describe its protocols for information protection.

Item P3. Description of your Technology
Include as an attachment to your application a summary of your Technology. This summary
should be more detailed than your response to P2.2 and may include proprietary or sensitive
information. Consider the following questions when preparing your response:
• What is your Technology? You may include information you provide to your
customers when you sell that Technology.
• What is your Technology intended to do?
• What are its principal elements, systems, or components?
• How does it operate?
• How and where may it be utilized?
• If your Technology is a service, or incorporates a service, describe the actions,
activities, planning, training, and/or expertise involved.
• What specific potential to counter terrorism does your Technology have? In
particular, what sorts of terrorist attacks or attempted terrorist acts could be deterred,
mitigated, or otherwise addressed by your Technology?
DHS Form 10009 (10/06)

Item P4. Past sales
Who has previously purchased or utilized your Technology? What sales do you anticipate?
When? Check and complete each line that applies.

Item P5. Readiness for Sale
Indicate how ready your Technology is to be sold by checking the appropriate box.

Item P6. Effectiveness
Include as an attachment to your application a summary of information available to
demonstrate the usefulness and effectiveness of your Technology. The summary
information you provide here should include information demonstrating your belief that
your Technology can be a valuable counter terrorism tool. The kind of information your
summary should include will depend on the nature of your Technology. Please indicate any
deployments for military or governmental customers. It may be very important and could
significantly expedite your eventual application if your Technology has been acquired or
utilized (or is subject to an ongoing procurement) by the military, a Federal government
agency, or a state or local governmental entity. Procurements of your Technology by a
foreign government may also have significant relevance.
If your Technology is primarily a device or software product, your summary should briefly
describe available developmental and operational test data that indicate the likely operating
performance of that device or software. This could include performance in past
deployments, independent test results, government licenses or certifications, field tests (e.g.,
performance against simulated attacks), internal test data, customer studies, scientific studies
of the techniques involved, industry reports, government or military publications, or any
other information that suggests or supports the potential usefulness of your Technology.
If your Technology is primarily a service, your summary should describe the nature and
quality of the process or expertise involved and should include any available information of
successful past deployments of a similar nature. Indicate whether those involved in
providing the QATT have certain specialized training or certifications. In particular, you
should also summarize available information that documents any of the following:
• The nature and quality of the services you provide.
• Your specification (or any governmental specification) for the processes used to
provide those services. If formal protocol or processes exist, please describe them.
• Your methods for monitoring your adherence to your processes.
• Your means for measuring the success of a particular deployment of your services.
• Your expertise or reputation as a provider of these services.
• Compliance with standards from recognized standard setting organizations.

DHS Form 10009 (10/06)

Item P7. Liability Considerations
In an attachment, please identify the types of potential terrorist activity the Technology is
intended to address. Please describe, to the extent practicable, the scope of damage, loss of
life, or other harm that could result from such terrorist activity. Please describe how your
Technology has been deployed to date to counter this type of terrorism or will be deployed
in the future should SAFETY Act Designation be issued. Please also describe how
deployment of your Technology may be affected should your Technology not receive
SAFETY Act Designation. Please include information relating to whether the timing of the
deployment of your Technology will be affected.
You need not attach copies of any referenced reports, publications, or other
information as part of this Pre-Application. However, be aware that such
information should be provided as part of a full Application.

DHS Form 10009 (10/06)