Form DHS Form 9012 DHS Form 9012 Chemical-terrorism Vulnerability information Training &

Department of Homeland Security Chemical-terrorism Vulnerability Information Training & Authorized User Application

OMB Control Number 1670-0015 Expiration Date 11/30/2024

Burden Statement

The public reporting burden for the Chemical-terrorism Vulnerability Information (CVI) Training and Authorized User Application is estimated to be 30 minutes. The burden estimate includes time for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. You may send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to cfats@hq.dhs.gov.

Completion of the CVI Training and Authorized User Application is necessary for CISA to issue you a CVI Authorized User Number.

Privacy Act Statement

Authority: Prior to July 28, 2023, 6 U.S.C. § 623 and 6 C.F.R. § 27.400 provided authority for certain information developed pursuant to the Chemical Facility Anti-Terrorism Standards program, 6 C.F.R. Part 27 to be designated as Chemical-terrorism Vulnerability Information (CVI). Although Congress has allowed the statutory authority for the CFATS program to expire, this information collection can proceed under 6 U.S.C. 652(e)(1)(J), which grants CISA the authority to safeguard information from unauthorized disclosure and to ensure that information is handled and used only for the performance of official duties.

Purpose: This collection is used to register respondents as a Chemical-terrorism Vulnerability Information (CVI) Authorized Users, issue unique CVI identification numbers, verify CVI Authorized User status, or contact respondents regarding their submission.

Routine Uses: The Personally Identifiable Information (PII) you provide will be used by and disclosed to DHS personnel, contractors, or other agents, including but not limited to other Federal, state, and local officials; and used to contact the submitter and conduct any administrative follow up actions required to ensure compliance with the Chemical Facility Anti-Terrorism Standards. A complete list of the routine uses can be found in the system of records notices associated with this form, “Department of Homeland Security/ALL-002 Mailing and Other Lists System, November 25, 2008, 73 FR 71659” and; “Department of Homeland Security/ALL-004 General Information Technology Access Accounts Records System (GITAARS), November 27, 20212, 77 FR 70792.” The Department’s full list of system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.

Consequences of Failure to Provide Information: Providing this information is voluntary. However, failure to provide any of the information requested may result in an individual not becoming a CVI Authorized User, not being able to verify CVI Authorized User status, or DHS not being able to contact respondents regarding their submission.

Instructions

Please complete the CVI Training, read and affirm the statements, and complete the Authorized User application below.

CISA will review the application, and if approved, provide to you a unique CVI Authorized User number to confirm your status.

I hereby acknowledge that I am familiar with CVI standards set out in:

• 6 U.S.C. § 623

• 6 CFR § 27.400

I hereby acknowledge that I am familiar with or have been provided access to the DHS Revised Procedural Manual entitled “Safeguarding Information Designated as Chemical-terrorism Vulnerability Information (CVI),” dated September 2008.

I hereby agree to abide by any other requirements that may be officially communicated to me by the Cybersecurity and Infrastructure Agency (CISA) pursuant to 6 U.S.C. § 652(e)(1)(J).

First Name: Middle Initial:

Last Name:

Organization Name:

Organization Type: (Choose One)

Chemical Facility employee	DHS Employee	State or local gov’t. employee
Chemical Facility contractor	Federal gov’t employee	State or local gov’t contractor
Vested Private Third Party	Federal gov’t contractor	Other:

Business Mailing Address:

City: State: Zip Code:

Telephone: Ext: Email:

Describe Official Duties:

Direct Supervisor’s Name:

Supervisor’s Telephone: Ext:

DHS Form 9012 3