Form DHS Form 10088 DHS Form 10088 FORMAL EXPRESSION OF INTEREST (EOI) TO PERFORM A CHEMICA

DEPARTMENT OF HOMELAND SECURITY

Department of Homeland Security (DHS), Office of Health Affairs (OHA) Chemical Defense Program

ATTACHMENT A: FORMAL EXPRESSION OF INTEREST (EOI)

_{TO PERFORM A CHEMICAL DEFENSE DEMONSTRATION PROJECT}

OMB Control #: ########### Expiration Date: XX-XX-XXXX

Form Overview

The information will be used by the Department of Homeland Security Office of Health Affairs (OHA) to evaluate the interest level for State, Local, Tribal and Territorial (SLTT) agencies to participate in a chemical defense demonstration project performed by the Department of Homeland Security Office of Health Affairs.  The project aims to help enhance selected communities’ preparedness against high consequence chemical events (resulting from intentional or unintentional purposes).  Although the projects are venue-specific (e.g., sports stadium, outdoor port, theater or convention center) in order to perform targeted chemical threat risk assessment and preparedness against these events, the products derived from these projects have vast applicability to the community as a whole.  Please complete the information requested within 30 calendar days from the EOI’s release date, as published through the Federal Register.  SLTT agencies may submit the completed form electronically, to include an electronic signature; scanned to Joselito.Ignacio@hq.dhs.gov; or faxed to (202) 254-2295.

Form Instructions

Items 1-7. This section provides the primary point of contact’s information. Please provide the following: 1. name of State, Local, Tribal, or Territorial Government (SLTT) agency; 2. business address; 3. submitter’s name; 4. submitter’s title; 5. submitter’s business phone number; 6. submitter’s fax number; 7. submitter’s email address.

Item 8. Provide the name of the desired venue for this project.

Examples: “Stadium 123, Port of X, Somewhere Convention Center, Y Arena”

Item 9. Explain the SLTT agency’s reasons for desiring to enhance community’s chemical preparedness through this demonstration project. Please include your jurisdiction’s role in preparing or in responding to chemical incidents.

Item 10. Explain your community’s reasons for desiring to enhance community’s chemical preparedness. Please explain specific community concerns, which may include threats to mass gatherings, nearby chemical manufacturing, storage or distribution facilities, and other relevant information.

Item 11. Identify specific reasons why this venue is the desired target for this demonstration project. Example: “Location ABC is the site of three annual events hosting more than 50,000 participants at each event. Location ABC is less than two miles from a large factor which manufactures chemical XYZ”.

Item 12. Explain any chemical threat risk assessments conducted in the community and/or on this particular venue. Please discuss the performer conducting the assessment and general summary of the results, if unclassified or otherwise unprotected.

Item 13. Provide any additional information that you wish DHS/OHA to consider as related to performing a chemical defense demonstration project. This information should include any information that might be considered important for the venue to be selected. This can include additional chemical defense efforts, current or past efforts with DHS, etc.

Item 14. Sign and date the form in order to certify that the statements on this form are true and complete. Digitally scanned signatures and digitally created signatures are accepted.

DEPARTMENT OF HOMELAND SECURITY

Department of Homeland Security (DHS), Office of Health Affairs (OHA) Chemical Defense Program

ATTACHMENT A: FORMAL EXPRESSION OF INTEREST (EOI)

_{TO PERFORM A CHEMICAL DEFENSE DEMONSTRATION PROJECT}

OMB Control #: ########### Expiration Date: XX-XX-XXXX

1. Name of State, Local, Tribal, and Territorial (SLTT) Government Agency:

2. Address:

3. Submitter’s Name: 4. Title:

5. Phone Number: 6. Fax Number:

7. E-mail Address:

8. Indicate a selected venue to be considered for this capability:

9. Explain agency interest in developing a chemical defense capability through this demonstration project:

Submission Receipt Date:

Note: Attach additional sheets if more explanation to any section is necessary.

For Internal Use Only

Submission Number:

_{10. Specific reasons for your community's interest in developing this capability:}

11. Specific reasons why this venue needs a chemical defense capability:

12. Explanation of the chemical threat risks assessed (based on any local or state research, if applicable) that may affect this venue:

13. Provide any additional information that you wish DHS/OHA to consider as related to performing a chemical defense demonstration project:

14. I certify that the statements on this form are true and complete.

Signature: Date:

In compliance with the Privacy Act of 1974, the following information is provided: AUTHORITY: HR 2055, Consolidated Appropriations for 2012. PURPOSE: The primary purpose of the requested information is to determine eligibility for jurisdictions to host a Chemical Defense Demonstration project and to record and maintain requests for such assistance from the Government. USE: The information will be used by Federal agency officers and employees who have a need for the information in the performance of their official duties. The information may be disclosed to appropriate Federal, State, local, or foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions. Disclosure of the requested information is strictly voluntary in all instances; however, failure to provide the information required to support the application may result in delay or denial of selection.

The public reporting burden to complete this information collection is estimated at twenty hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and the 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, joselito.ignacio@hq.dhs.gov, ATTN: PRA [OMB Control Number].

DHS Form 10088 (9/12)

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