Form DHS Form 9027 DHS Form 9027 Report of Potential Release of Chemical-Terrorism Vulner

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1670-0015
Expiration Date: March 31, 2013

REPORT OF POTENTIAL RELEASE OF
CHEMICAL-TERRORISM VULNERABILITY INFORMATION (CVI)
Contact Information for Individual Submitting Report:
1a) Are you a CVI Authorized User?
Yes

1b) If yes, provide CVI Authorization Number:
CVI -

No

2) Name: (Last, First, MI)

3) Phone Number:

4a) Chemical Security Assessment Tool (CSAT)
Facility ID #

4b) Facility Name:

Potential CVI Violation
5) Please Check One:
A person without a need to know requested CVI

Materials containing CVI were suspected of compromise

CVI has been released to persons without a need to know

Unauthorized disclosure of materials containing CVI

Materials containing CVI were lost

Other:

Materials containing CVI were compromised

6) Date of Event:
7) Description of Incident

8) Other Relevant Facts:

9) Mitigation:

My statements in this submission are true, complete, and correct to the best of my knowledge an belief and
are made in good faith. I understand that a knowing and wilful false statement on this form can be published by
fine or imprisonment or both (see section 1001 of title 18, United States Code).
Signature:

DHS Form 9027 rev (10/09)

Date:

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

OMB No. 1670-0015
Expiration Date: March 31, 2013

DEPARTMENT OF HOMELAND SECURITY
REPORT OF POTENTIAL RELEASE OF CVI
INSTRUCTIONS
(Read the following instructions carefully before you complete this form.)
(Please complete all items on the form.)
GENERAL: This form should be used to report a potential release of CVI.
1.

Indicate your CVI number on the form. If you do not know your CVI Authorized User ID number, please contact the help
desk for assistance.

2.

Please provide your full name .

3.

Please provide a phone number where you can be reached at. When providing your phone number,
only input numeral digits into the given space.

4.

Please provide the the name of your facility or the facility who's CVI was shared and the CSAT facility's ID
number. If you do not know the CSAT facility ID number, please contact the help desk.

5.

Indicate by checking the box that best describes the potential violation. If it is not listed, check the "other"
box and describe in the space given.

6.

Please provide the date of the potential violation. Choose the date by clicking on the calendar.

7.

Please provide a detailed description of the potential violation (i.e., who was involved, what happened, other witnesses
of the incident, where it took place, and etc.)

8.

Please describe any other relevant facts about the potential violation.

9.

Please describe what had been done to respond and minimize the potential impact of the potential violation.

WHEN TO FILE: In accordance to Section 550 of P.L. 109-295, the implementing regulations 6 CFR Part 27
WHERE TO FILE: This form can be submitted to DHS via mail at Mail Stop 8100, Department of Homeland Security, Washington,
DC 20528-8100. Keep a copy of the completed form for your records.

PRIVACY ACT STATEMENT
Authority: 5 U.S. C. § 301 and 44 U.S.C. § 3101 authorize the collection of this information.
Purpose: DHS will use this information to register you as a Chemical-terrorism Vulnerability Information (CVI) Authorized User, issue your
unique CVI identification number, verify your CVI Authorized User status or contact you regarding your submission.
Routine Use: This information may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended.
This includes using the information, as necessary and authorized by the routine uses published in DHS/ALL-004 General Information
Technology Access Account Records System of Records (September 29, 2009, 74 FR 49882).
Disclosure: Furnishing this information is voluntary; however failure to provide any of the information requested may result in you not
becoming a CVI Authorized User, not being able to verify your CVI Authorized User status or not being able to contact you regarding your
submission.

PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act, no one is required to respond to a collection of information unless it displays a valid
OMB Control Number. The valid OMB Control Number for this information collection is 1670-0015. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

DHS Form 9027 rev (10/09)

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays