Form EPA 7740-6 EPA 7740-6 Contractor Acces to TSCA CBI

Appendix A Please read the instructions on reverse before completing this form.
OMB Control No. 2070-0075
United States Environmental Protection Agency
Washington, DC 20460

TSCA CBI Access Request, Agreement, and Approval
Section I. – Access Request

1. Name (Last, First, MI)
3. Requestor
(Agency/Region/Office/Division/Branch)

2. Telephone Number

4. Document Control Officer (DCO)

6. TSCA Sections for which access is
required. Check all that apply. Use blank
space to request other sections not listed.

- OR-

ALL

4

NONE

5

6

5. DCO Telephone Number

8

12

13

21

Only access to Secure Storage Areas (SSAs).

7. Justification for TSCA CBI access.
Select appropriate code from instructions on reverse side. (Check one for all that apply).

8. Employer’s Name

A

B

C

D

Section II. – Contract Information - Contractor Employees Only

10. Contract Number

9a. Employer’s Address

9b. City

9c. State

11. EPA Contracting Officer’s Representative (COR)

12. EPA COR Telephone

9d. Zip code

Section III. – OPPT Secure Storage Area Access – HQ Federal and HQ Contractor Employees Only

13. Check if EPA ID Badge is required.
Yes (New)

14. List OPPT Restricted areas by Division to which physical access is required.

No

Home Division (24-hour access)

Other Divisions (6A.M. – 6P.M. only)

Access to CBIC

CBI Computer Rooms
B149
IMD Computer Room

15. List OPPT areas by Division and Room Number for which Alarm Activation/Deactivation Authority is requested.

Section IV. – Virtual Desktop Infrastructure Agreement

I require access to TSCA CBI and other materials accessible via the virtual desktop to perform my assigned duties. I have read, understand the requirements,
and agree to adhere to the guidelines, policies, and provisions as set forth in the rules of behavior document. My use and access of TSCA CBI and other
materials via the virtual desktop will comply with all applicable policies, standards, and applicable laws as referenced in the TSCA CBI Protection Manual, and
other applicable Agency rules and procedures.
User’s duties require the ability to access the CBI LAN from within an SSA at the EPA.
User’s duties require the ability to work remotely from an Alternate Work Site utilizing VDI remote access.

YES

NO

YES

NO

I have a job-related need for file transfer, confirmed by my supervisor, which necessitates the transfer of files and/or other data to and/or from the CBI LAN to a
non-CBI environment using the virtual desktop. Any CBI files or data that are transferred from the CBI LAN to a non-CBI environment will be completely
removed from the non-CBI environment once the job-related task has been accomplished.
YES
NO
I understand that I will have access to certain Confidential Business Information submitted under the Toxic Substances Control Act (TSCA, 15 U.S.C 2601 et
seq.). This access has been granted in accordance with my official duties relating to Environmental Protection Agency programs. I understand that my
obligation to protect TSCA CBI, which has been disclosed to me as part of my official job duties, continues after either termination of my assignment or
termination of my employment.
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any knowingly false or
misleading statement may be punishable by fine or imprisonment or both under applicable law.
TSCA CBI may be used only in connection with my official duties and may not be disclosed except as authorized by TSCA and Agency regulations. I have received a
copy of, and understand the procedures set forth in, the TSCA CBI Protection Manual. I agree that I will treat any TSCA CBI furnished to me as confidential and that I will
follow these procedures.
I understand that under section 14(d) of TSCA (15 U.S.C. 2513(d)), I am liable for a possible fine of up to $5,000 and/or imprisonment for up to one year if I willfully
disclose TSCA CBI to any person not authorized to receive it. In addition, I understand that I may be subject to disciplinary action for violation of this agreement
with penalties ranging up to and including dismissal.
16. Signature of Employee

18. TSCA CBI Security Briefing Date

21. DCO Code

17. Date

Section V. – Requesting Official Approval

19. Name and Signature of Requesting Official. (Immediate Supervisor – EPA COR for Contractors). I certify
he/she has successfully completed a TSCA CBI Briefing on the date shown.
Name
Signature
20. Date
22. Approved HQ EPA (TSCA Security Official Signature)

EPA Form 7740-6 (Rev. 06-19). Replaces previous version of 7740-6 and 7740-6A.

23. Approval Date

Paperwork Reduction Act Notice
The public reporting burden for the collection of information is estimated to average .84 hours per response. This estimate includes time for
reviewing instructions, gathering and maintaining the needed data, and completing and reviewing the collection of 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. This collection of
information is voluntary for access. Send comments regarding the burden estimate or any other aspect of this collection of information to the Director,
Collection Strategies Division, US Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington DC 20460, and to the Office of
Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503, marked ATTENTION: Desk Officer for EPA. Include the
OMB No. identified on page 1 in any correspondence. Do not send the completed form to this address. Submit the form in accordance with the instructions
in the TSCA CBI Protection Manual.

Section I – To be completed by all

Instructions for Form Completion
Section III – To be completed by HQ Federal
and HQ Contractor employees only

1. List Full Name.
NOTE: These procedures apply only to employees requiring access to
OPPT Secure Storage areas. All others follow standard Agency
2. List Telephone number of person in item 1.
procedures.
3. List Full Acronym of Requesting Office (i.e. EPA Office in which the
13. Check either yes, or no for EPA ID badge or Contractor Building
individual works or for contractor employees, the EPA Office with whom
the contract is with).
Pass.
4. List the immediate Document Control Officer for the office in which
a. Yes – Check if new employee getting first EPA ID Badge.
(New programmed badge and barcode).
the individual works.
5. List the telephone number of the Document Control Officer.
b. No - Existing badge needs programming.
6. Check the TSCA Sections for which access is requested or check
14. Check and list OPPT secured areas for which access (electronic door
ALL if applicable.
control system) is required. List Division acronyms for the requested areas.
7. Select the appropriate Access Justification code.
Home Division - List Division in which employee works.
A. Employee is an EPA employee or EPA contractor employee whose
Other Divisions - List other OPPT Divisions for which unrestricted daytime
work assignments involve the New and/or Existing Chemical
access is requested.
Programs of TSCA. Hence access to the TSCA sections listed in item
Access to CBIC- Answer yes for those who only need to access
7 of this form is required in performance of his/her duties.
the Confidential Business Information Center.
B. Employee is an EPA employee or EPA contractor employee whose work
CBI Computer Rooms – IMD Areas - Only IMD staff and contractors who
entails the administration of computer systems housing TSCA CBI.
work in B149 and IMD computer rooms should check the box for B149 or
Hence access to the TSCA sections listed in item 7 of this form is
IMD Computer Rooms.
required.
15. List OPPT areas by Division and Room numbers for which Alarm
C. Employee is an EPA employee or EPA contractor employee whose
Activation/Deactivation authority is requested. Generally, this is employees
work entails physical security or maintenance for TSCA CBI secure
home Division only.
storage areas. Although employee will not actually work with any
TSCA CBI materials, access to the TSCA sections listed in item 7 of
Section IV – To be completed by all
this form is required.
Check yes or no for user's duties require the ability to access the CBI LAN.
D. List Justification here.
Check yes or no for user's duties require the ability to work remotely from
Check yes or no for job related need for file transfer.
16. Employee signature.
17. Signature Date.

Section II – To be completed by Contractor
Employees only
8. List Employer’s name.
9a-d. List Employers address.
10. List Contract Number.
11-12. List EPA COR Name and Telephone number.

Section V- To be completed by all
18.
19.
20.
21.
22.
23.

Enter date employee attended TSCA CBI Security Briefing.
Immediate supervisor/EPA COR’s name and sign.
Date of signature.
DCO Code.
Approved by HQ EPA TSCA Security.
Date approved.