Form DHS Form 9500 DHS Form 9500 Filter Holder Log

DEPARTMENT OF HOMELAND SECURITY

FILTER HOLDER LOG

OMB Control Number: 1601-0006
Expiration Date: 10/31/2011

Office of Health Affairs/BioWatch
Systems Program Office
Site Number

Filter Installation
Date

Time

PSU #

Filter Holder ID
Elapsed Time Meter at Start

Field Operator (print)
On Arrival:

Filter Holder Bag Intact

On Leaving Site:

Holder compartment Locked
Fan on

Filter Installation Check

Pump Compartment Locked

Turn on Pump
Flow Rate at Start

lpm

Signature:

Comments / Field Flags:

Filter Removal
Date

Time

Flow Rate at Stop
Elapsed Time Meter at Stop

PSU #
lpm

Field Operator (print)

Turn off Pump

Physical Security Check

Clear Meter

On Leaving Site:

Sample Bag Sealed
Holder Compartment Locked

Exposed Filter Holder ID

Fan on

Pump Compartment Locked

Exposed Filter Holder Double Bagged
Signature:
Comments / Field Flags:

DHS Form 9500 (7/11)

Lab - White (Original)

Field / SMS - Yellow (Completed Cycle)

Field-Pink - (Field Operator's Copy)

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Please read the instructions on the reverse before completing this log. For additional logs or assistance in completing this log, contact DHS Chem/Bio Systems Program Office.

Instructions For Completing Filter Holder Log
PRINCIPAL PURPOSE: The purpose of this log is to support daily operations of the Department of Homeland Security's (DHS) BioWatch Program. The
log is required to create a unique written chain-of-custody record tied to each collected filter sample to support law enforcement activities, including
criminal prosecution in the case of a deliberate release of a biological warfare agent.
Blocks: Complete the requested information for each block by filling in all entry blanks. In the Comments/Field flags block, the field operator is able to
write any additional comments or observations made during the filter removal/installation process. Be as specific as possible when completing this log.
Please write legibly.
Boxes: Place a check mark in the appropriate box to identify the type of collector being serviced. All other boxes require a check mark when the
corresponding action is completed or as a requested observation is validated.
Paperwork Reduction Act Statement: The public reporting burden to complete this information collection is estimated at 1 minute per respondent,
including the time for reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collected information. An
agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control
number and expiration date. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to DHS, Office of Health Affairs, Chem/Bio Early Detection Division, Washington, D.C. 20528: ATTN: PRA (1601-NEW).

DHS Form 9500 (7/11)

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