Form DHS Form 10007 DHS Form 10007 Application for Safety Act Certification

OMB Control No. 1640-0001
Expires: 03/31/2013

APPLICATION FOR SAFETY ACT CERTIFICATION
SAFETY Act Certification provides Sellers of a QATT with an additional measure of
liability protection. The Sellers of QATTs that receive SAFETY Act Certification are
entitled to all of the liability protections that accompany SAFETY Act Designation as well as
the rebuttable presumption that the Government contractor defense applies to claims arising
out of, relating to, or resulting from an act of terrorism. In addition, QATTs that received
Certification will be placed on the Approved Products List for Homeland Security.
A Certification application may be submitted along with a Designation application or may be
submitted after SAFETY Act Designation has been issued. However, a Technology may
not receive Certification without having first received Designation.
To receive SAFETY Act Certification, the Department must conclude that the Technology
“will perform as intended, conforms to the Seller’s specifications, and is safe for use as
intended.”1

(Certification Application Form on following page)

1 6 USC § 442(d)(2).
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 03/31/2013. The estimated average time to complete this form is 40 hours 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 10007 (10/06)

APPLICATION FOR SAFETY ACT CERTIFICATION
APPLICATION TYPE
C1. Type of Application. This application is a(n) (choose one):
Initial Application Filing for a Certification, please provide Designation Application
ID#:____________________________________________________________
Resubmission of a Previous Application for Certification, please provide Designation
Application ID #:________________________________________

EXPEDITED REVIEW
C2. Request for Expedited Review
In its discretion, the Department may identify categories of anti-terrorism technologies for
which expedited processing may be granted. For example, the Department may conduct
expedited processing for applications that are the subject of a pending or past Federal,
State, or local procurement, which address a particular threat, involve particular types of
anti-terrorism technologies, or do so for other reasons. Depending on the nature of the
procurement, this may substantially expedite and simplify the application process. If you
are requesting expedited review, please specify the basis for such a request, including, if
applicable, information concerning an ongoing procurement. Such information should
include the following:
a. The name of procuring organization;
b. Contact information for the relevant Government procurement officials;
c. The related Request for Proposal (RFP) number or other official identifier of the
procurement, if available; and
d. Upcoming deadlines relating to the procurement (e.g., submission deadline,
decision/contract award, etc.).
Please note if your application falls under a published DHS Notice of Expedited
Processing and provide the reference number for such notice and a brief statement as to
why your application falls within the scope of the Notice of the Expedited Processing.
If you wish to provide other bases for expedited processing, please specify.

REGISTRATION INFORMATION
C3. Registration Status (choose one):
I am updating or correcting previous registration information.
My previously provided registration information is still accurate:
C3.1. Seller Name: _______________________________________________________________

DHS Form 10007 (10/06)

CERTIFICATION
Respond to all items in this section in one attachment to this application. Additional
supporting material may be attached as an appendix to your application.
C4. Performs as Intended. Define what it means for your Technology to perform as intended,
and provide information and/or data establishing that your Technology performs as
intended. This information may be the same as, or in addition to, information provided
for an Application for SAFETY Act Designation.
If POCs are provided as sources of information or testimonials, check below to indicate
that you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate below what information we should expect from each
POC.
The POCs are expecting contact from DHS. The information the POC can provide or
verify is:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
C5. Conforms to Seller’s Specifications. Describe the processes and procedures you use to
ensure that each sale of your Technology conforms to the applicable specifications. If
your Technology was or is involved in a Government procurement, acceptance of the
Technology by the Government and related testing may be highly relevant here. Provide
available documentation demonstrating that your Technology conforms to established
specifications.
If POCs are provided as sources of information or testimonials, check below to indicate
that you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate below what information we should expect from each
POC.
The POCs are expecting contact from DHS. The information the POC can provide or
verify is:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
C6. Safe for use as intended. Provide available analyses evidencing that the Technology is safe
for use as intended. Please note any known or suspected hazards or safety risks associated
with your Technology. Please provide safety and hazard analyses for your Technology.

ADDITIONAL ATTACHMENTS
Provide additional supporting documentation.
DHS Form 10007 (10/06)

DECLARATION FOR WRITTEN SUBMISSIONS
I declare, to the best of my knowledge and belief, that the information provided in
response to the questions set forth in this Application for SAFETY Act liability protections
is true, factual, and correct, and that I am an authorized agent of the Applicant.
Prepared By: ________________________________

Title (if applicable): _______________

Signature: ______________________________________________ Date: ___/___/20__

The signature of the Preparer must be notarized below:
State of:

_______________

Subscribed and sworn before me this

Notary Public:

_____

day of

_____________________

___________________________________________________

My Commission Expires on:

DHS Form 10007 (10/06)

County of: __________________________

________________________________________

Instructions for Completing Certification Application Form:
Application Type
Item C1. Type of Application
If you have not previously filed an Application for SAFETY Act Certification for this
Technology, check “Initial Filing.”
If you have previously applied for SAFETY Act Certification for this Technology,
check the second box: “Resubmission of Previous Application for Certification.”
This case applies if any previous applications for this Technology were found to be
incomplete, were withdrawn, or were declined. Previously incomplete or declined
applications will not adversely affect the evaluation of your current application. This
information is requested for administrative and record-keeping purposes only.

Expedited Review
Item C2. Expedited Review
In its discretion, the Department may identify categories of anti-terrorism
technologies for which expedited processing may be granted. For example, the
Under Secretary may conduct expedited processing for applications that are the
subject of a pending or past Federal, State, or local procurement, which address a
particular threat, that involve particular types of anti-terrorism technologies, or for
other reasons. If you are requesting an expedited review, please specify the
appropriate basis for expedited treatment of your application.
If your Technology is the subject of a pending Government procurement or if you
are planning to submit a proposal for a procurement decision in the near future,
provide the following information to the extent available:
a. Name of procuring organization;
b. Contact information for relevant Government procurement officials;
c. Related Request for Proposal (RFP) number or other official identifier of
the procurement; and
d. Upcoming deadlines relating to the procurement (e.g., submission
deadline, decision/contract award, etc.).
If your request to expedite falls under a published DHS Notice of Expedited
Processing, please provide such notice’s reference number and follow the instructions
set forth in the announcement.
If your request to expedite is not related to procurement, please provide the basis for
your request and provide available supporting information.

DHS Form 10007 (10/06)

Registration Information
Item C3. Registration Information
Please check the appropriate box relating to your registration status.
Item C3.1. Name of Seller/Applicant
Enter your Seller name as listed on your registration form.

Certification as an Approved Product for Homeland Security
Just as in the Application for Designation’s “ATT Details” Section, you should
respond to the following items in a single attachment as a narrative response. Each
item requires an affirmative response. Just as in the Application for Designation, it is
vital that you cross reference the supporting documentation to each claim you make
in order that our reviewers understand what material you wish us to evaluate.
Documentation in support of certification items should be included in the Table of
Contents for exhibits attachment for the Designation Application.
Do Not:
• Simply list a point of contact with the intent that DHS will seek out
information on your behalf. It is your responsibility to provide all information
which supports the capability and effectiveness of your Technology at the
time of your submittal. While we may be able to obtain some information in a
timely fashion, failure to take the appropriate steps to ensure transmittal of
this information could result in a delay in the processing of your application or
an unfavorable evaluation result.
• Simply list or refer to previous sections in response, e.g. “See Item D.9 in the
Designation Application”. We have no way of knowing what information you
are actually referring to in a previous item which provided support for an item
in the Certification Application. Also bear in mind, that while some questions
may appear duplicative, all application items are targeted to specific criterion,
and each require a response. You may refer to previously stated information;
however, you must indicate its specific relevance to the new question.

Item C4. Performs as Intended
Provide support for the claim that your Technology will perform as intended.
Explain what it means for your Technology to perform as intended and include
information demonstrating that the Technology will, under reasonable circumstances,
consistently perform as intended over time. This information may be the same as, or
in addition to, information provided for an application for SAFETY Act Designation.
The kind of documentation you should provide will depend on the nature of your
Technology. If your Technology is primarily a device or software product, then your
documentation should emphasize the likely operating performance of that device or
DHS Form 10007 (10/06)

software. This will require that you demonstrate that your Technology is effective for
its intended use AND that it will perform reliably. You may consider providing
information regarding the continuing ability of your Technology to perform and be
used in accordance with specifications. Such specifications could include, for
instance, elements such as detection limits, mean time between failures, probability of
detection, false positive/negative rates, or other metrics. You may include, for
instance, any Government acceptance testing, third-party evaluations, or other
objective data. Measures of effectiveness include evidence of quality control plans,
reliability data, evidence of reproducibility between deployments, and evidence that
customers can install, use, and maintain the system. This might include procedures to
test your Technology over time. The Technology might also have defined
performance specifications that are consistently met while the Technology is in
operation.
If your Technology is primarily a service, you should provide information on the
effectiveness of the core capabilities of the service. Combined with the information
that you have provided in your Application for Designation in item D.14 related to
effectiveness, this item is a look at the future or continued effectiveness of your
Technology. Information that should be provided in support would include all
measures employed to ensure the consistency of your Technology, such as:
• Quality control plans and policies
• Periodic testing
• Continuing education policies
Information supporting the effectiveness of your service could include such items as
sound quality assurance processes, internal or external auditing services to ensure that
the processes remain current, performance review strategies, employee screening
procedures and certification requirements, documented practices of updating
employee training, processes for maintaining currency of training and intelligence
information, and similar factors. If you have successfully deployed the Technology
or a substantially similar project multiple times with success (i.e., testimonials,
independent assessments, etc.), then you may provide this information as evidence of
the performance of your Technology. You may, when applicable, demonstrate
reproducibility by adherence to well-recognized national or international standards.
You may include, as an attachment to your application, the supporting or referenced
material that is not publicly available. If you refer to information provided elsewhere
in your application, cite it by internal title, item number, or the name of the
attachment.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology.

DHS Form 10007 (10/06)

Also, please be advised that:
1. The SAFETY Act may make contact with persons that you list as having
information to support the claims in your Application; however it is your
responsibility to make sure that you have provided all information to
support your Application at the time of submission. Do not simply include
a listing of your customers for DHS to contact. We suggest that you obtain
written testimonials from your customers.
2. If you believe that third-parties will be able to provide additional
supporting information for which you do not have access (such as for
example, classified reports, audits, vulnerability assessments, or other
reports or data), remember to:
a) Be sure that the contact information you provide to us is
current.
b) Notify your references that you have submitted a SAFETY Act
application and that we may contact them.
c) Make sure that you are giving us the contact that will be able to
provide the best information on the nature of the past sale or
deployment, and on how your technology actually worked.
d) You may also supply contact information for third-parties, e.g.,
government officials, who might supply customer testimonials.
These individuals should be able to supply actual knowledge of
how your technology works and of its utility. We suggest that
you obtain this information in writing.
e) For procurements, list the name and contact information for
the procurement officer or similar person in charge of the
contract, proposal, or Request for Proposal.

Item C5. Conforms to Seller’s Specifications
Provide support for the claim that your Technology conforms (and will continue to
conform) to the applicable specifications. For products, technical specifications
should include those items that are invariable from deployment to deployment, such
as size, weight, or services provided with the sale of the product (maintenance,
warranties, etc.). Consideration should be given to factors such as compliance with
manufacturing standards, factory acceptance testing procedures, site acceptance
testing procedures, quality control processes and procedures, and quality assurance
plans. Government acceptance of your Technology and related testing may be highly
relevant to these areas.
For services, specifications might consist of the processes and procedures that dictate
the implementation of the service. Such processes could be given in a standard
operating procedure document or a process manual. You might also supply this
support through a “Statement of Work” or through a response to a “Request for
Proposal.” Additionally, you should provide information that a process is in place to
ensure conformity with those specifications, such as a well-defined quality assurance
DHS Form 10007 (10/06)

plan or adherence to applicable industry standards. In cases where standards do not
exist or apply, you should show some mechanism to ensure conformity with
specifications, such as periodic internal or external reviews of the service’s
fundamental processes. Again, Government acceptance/use of your Technology
may be highly relevant.
Your response may consist of an overview narrative including references and
summaries of supporting documentation. You may include as an attachment to your
application any of the supporting or referenced material that is not publicly available.
The Department requires this information to perform its comprehensive review of
the design of your Technology to determine whether it conforms with your
specifications.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. See instructions for C.4 for more information on POCs.

Item C6. Safe for Use as Intended
This item is intended to understand all potential safety risks of your technology for
the Seller, end-user, and for bystanders. Just because a technology appears to be risk
free, e.g., training, for example, does not mean that it might not carry a hazard.
Please provide information that your Technology is safe for use as intended. Provide
a safety and hazard analysis for your Technology.
The SAFETY Act (6 USC § 442(d)(2)) requires that the Seller conduct and provide to
the Department safety and hazard analyses for the Technology being considered for
SAFETY Act Certification. Your safety and hazard analyses should discuss:
•
•
•
•
•
•

Documentation pertaining to the safety of your Technology.
Known hazards associated with any part of the lifecycle of your Technology.
Any potential hazards to your employees.
Any potential hazards to the purchasers or operators of your Technology.
Any potential hazards to third parties.
Potential hazards arising from the Technology’s deployment in the event of an
act of terrorism.
• Potential hazards arising in the event of a false alarm.
• Potential hazards arising from improper deployment, use, or maintenance of
the Technology.
Your response may also include an overview narrative, including references and
summaries of supporting documentation. You may include, as an attachment to your
application, any of the supporting or referenced material that is not publicly available.
It is important that you supply information that indicates your understanding of any
inherent safety hazards connected with the sale or operation of your Technology and
the steps that you have takes to mitigate those hazards. Information which might be
DHS Form 10007 (10/06)

useful could include safety warning labels, training, and safety policies and
procedures.

Additional Attachments
In the process of answering the questions above, you might find it useful to attach
additional documents in support of your answers. These items can be included in
your application by using the “Additional Attachments” feature. When answering the
items above, it is appropriate to refer to attachments by name and/or number.
Examples of common attachments might include, but are not limited to, the
following: test reports demonstrating the effectiveness of the Technology, operating
manuals, training manuals, project/program management plans, quality assurance
plans, quality control plans, copies of test reports demonstrating effectiveness, results
from pilot studies, testimonials from customers, and warranties. The Department
will also accept any supplementary information concerning your Technology that you
feel will be helpful to the Department in analyzing your Technology.
Submitting Documents as Attachments:
Documents in support of your Application should be uploaded as Attachments
together with a separate numbered Table of Contents document. Attachments
should be individually labeled and or otherwise clearly identified. For ease of use, we
prefer that documents are uploaded individually, rather than in a “Zip” file. Ideally,
attachments should be cross referenced in your narrative response, with clear
indications of the purpose of the Attachment. It is usually unnecessary to upload
third-party material, such as government training presentations, regulations or
standards documents. You may refer to these documents in your narrative and
provide an open-source link. For additional assistance in uploading documentation,
or for further questions, please call the SAFETY Act Help Desk.
Submitting classified or sensitive data or information:
In cases where the effectiveness data, e.g., audits or testing, that you wish to have
evaluated is classified or sensitive and is held by a third party; the Department will
attempt to assist you in obtaining this information, however, you MUST facilitate the
transfer of that data to the SAFETY Act office PRIOR to the submission of your
Application. This means that you must notify the custodian of records for your
customer of your Application to the SAFETY Act and that Department requires
access to those records. Once you have completed this step, you must provide the
Department with the name and contact information of the holder of these records.
When a date has been set for the transfer of information, you may submit your
Application. For further assistance call the SAFETY Act Help Desk.
Declaration for Written Submissions

DHS Form 10007 (10/06)

An authorized agent of the Applicant must, in the presence of a Notary, sign and date
this form before submitting it to OSAI. For electronic or Web submissions, follow
the instructions provided at safetyact.gov.

DHS Form 10007 (10/06)