Form DHS Form 9024 DHS Form 9024 Notification of Chemical-Terrorism Vulnerability (CVI) A

DEPARTMENT OF HOMELAND SECURITY

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

NOTIFICATION OF CHEMICAL-TERRORISM VULNERABILTY (CVI) ACCESS
OR DISCLOSURE TO A NON-CVI AUTHORIZED USER DURING
AN EMERGENCY OR EXIGENT CIRCUMSTANCE
Contact Information for Individual Reporting:
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:

Relevant Details about the Emergency or Exigent Circumstances
5) Date CVI was Shared:
6) Who Received the CVI?

Name:
Agency:

7) Reporting Statement:

I disclosed CVI to an individual who was not a CVI Authorized User but had a need to know.
I provided access to an individual who was not a CVI Authorized User but had a need to know.
I transferred possession of CVI to an individual who was not a CVI Authorized User but had a need to know.
Other:

8) Method of Transmittal:
9) Reasons for emergency or
exigent access/disclosure:

10) Justification:

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 9024 rev (9/09)

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

NOTIFICATION OF CVI ACCESS OR DISCLOSURE TO A NON-CVI AUTHORIZED USER DURING
AN EMERGENCY OR EXIGENT CIRCUMSTANCE
(Read the following instructions carefully before you complete this form.)
GENERAL: This form should be used in the event a covered person discloses CVI under emergency and exigent circumstances
without standard precaution required by the regulations, 6 CFR Part 27. Notifying DHS will ensure appropriate mitigation actions to take
place to protect the disclosure 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.

To input the date of when CVI was shared, 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 name(s) and which agency/facility they represent.

7.

Please check which best describes the type of sharing which occurred.

8.

Please provide the method of transmittal. How was the CVI shared? (e.g., told over phone, e-mailed, etc.)

9.

Please describe in full detail the reasons for the emergency or exigent access/disclosure.

10.

Please provide the justification on the Need to Know.

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 9024 rev (9/09)

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