Form DHS Form 9028 DHS Form 9028 Request for Determination of Chemical-Terrorism Vulnerab

DEPARTMENT OF HOMELAND SECURITY

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

REQUEST FOR DETERMINATION OF
CHEMICAL-TERRORISM VULNERABILITY INFORMATION (CVI)
Contact Information for Individual Submitting Designation Request:
1a) Are you a CVI Authorized User?
Yes

No

1b) If yes, provide CVI Authorization Number:

CVI -

2) Name: (Last, First, MI)

3) Phone Number:

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

4b) Facility Name:

CVI Determination Information
5) Date of Request:
6) Subject / Title of the Request
7) Synopsis of the Information:

8) Justification:

9) Origin of Information:

10) Attachment:

I have attached the information that will be reviewed for determination of CVI

DHS will communicate its final determination to the submitter registered with DHS for the facility in question or the
appropriate point of contact at the other state, local, tribal territorial or other federal agencies.

DHS Form 9028 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

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

DEPARTMENT OF HOMELAND SECURITY
REQUEST FOR DETERMINATION OF CVI INSTRUCTIONS
(Read the following instructions carefully before you complete this form.)

GENERAL:

This form should be used in the event a facility develops information that could, in the facility's
judgement, compromise facility security if publicly disclosed and that information is not listed as CVI
under 6 CFR 27,400 (b) (1) - (8).

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.

To input the date of request, click in the given space and an arrow pointing downwards should pop up.
Click on the arrow and you can choose your date from the calendar.

6.

Please provide the subject or the title of your request. The subject/title should best describe your
information.

7.

Please provide a detailed description of the synopsis of the information.

8.

Please provide a detailed description of justification for why the attachments would be CVI. Please do not include CVI
in the synopsis.

9.

Please describe where the information originates from. Please do not include CVI in the description.

10.

When submitting form, attach the information that will be reviewed for determination of CVI.

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 9028 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