Form DHS Form 9026 DHS Form 9026 Determination of a Public Offical's Need to Know Specifi

OMB No. 1670-0015
Expiration Date: March 31, 2013
DEPARTMENT OF HOMELAND SECURITY

DETERMINATION OF A PUBLIC OFFICIAL'S NEED TO KNOW SPECIFIC CVI
Contact Information Public Official Submitting Request:
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) CSAT Facility ID #

4b) Facility Name:

5a) Name of the Agency:

5b) Name of the Official Representing the Agency:

Determination for Public Official Access to CVI:
6) Type of agency represented (please check one):

State

Tribal

Local

Other:

7) What Information or Type
of Information is being
requested?

8) Why is the Information
Needed?

Department of Homeland Security's Determination of the Public Official's Need to Know Specific CVI
To be filled out by DHS Official

DHS has determined that the requester has need to know information to this specific CVI.
DHS has determined that the requester does not have a need to know information to this specific CVI.
Other:

To the extent possible, facilities should provide to the public official the information requested in non-CVI form. In many cases,
a facility can provide a product that contains all of the necessary operational and facility-specific information and excludes CVI.
Where non-CVI documents are not sufficient, DHS encourages facility and public officials to cooperate to limit the scope of CVI
shared to that which State, local and tribal officials need to assure public safety and security. This may include sharing only a
portion of a CVI document and redacting or deleting the rest.
Approved by:

DHS Title:

Signature:

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

DHS Form 9026 rev (09/09)

OMB No. 1670-0015
Expiration Date: March 31, 2013
DEPARTMENT OF HOMELAND SECURITY
DETERMINATION OF A PUBLIC OFFICIAL'S NEED TO KNOW SPECIFIC CVI INSTRUCTIONS
(Read the following instructions carefully before you complete this form.)
(Please complete all items on the form.)
GENERAL:
1.

This form should be used when a facility needs to disclose CVI to officials in State, local and tribal
agencies to confirm they are authorized users and have a need to know.

7.

Indicate your CVI number on the form. If you do not know your are a CVI Authorized user, please contact
the help desk for assistance.
Please provide your full name.
Please provide a phone number where you can be reached at. When providing your phone number,
only input numeral digits into the given space.
Please provide the the name of your facility and the CSAT facility's ID number. If you do not know your
CSAT facilities ID number, please contact the help desk.
Please provide the name of the agency and the name of the official(s) representing the agency.
Check the box of which agency is being represented. If it's not listed, check the other box and provide the
name of the agency in the given space.
Please provide a detailed description of what information or type of information is being requested.

8.

Please explain why this information is needed.

2.
3.
4.
5.
6.

WHEN TO FILE: In accordance to Section 550 of P.L. 109-295, the implementing regulations, 6 CFR Part 27, and the
CVI Procedures Manual on www.dhs.gov/chemicalsecurity completion of the verification of need to know for public
officials should be promptly submitted.
WHERE TO FILE: DHS Form 9026 for Verification of Need to Know for Public Officials can be submitted to DHS via
mail at Mail Stop 8100, Department of Homeland Security, Washington, DC 20528-8100. Or email @ cvi@dhs.gov.
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.
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

DHS Form 9026 rev (09/09)