DHS Form 10009 REQUEST FOR A PRE-APPLICATION CONSULTATION

OMB Control No. 1640-0001 Expires: 03/31/2016

Department of Homeland Security

Science and Technology Directorate

REQUEST FOR A PRE-APPLICATION CONSULTATION

A Pre-Application Consultation is a voluntary means through which OSAI provides helpful guidance to potential applicants without requiring the completion and submission of a full SAFETY Act Application. The Pre-Application Consultation is intended to facilitate a process by which a potential applicant may provide DHS with initial information regarding their Technology, so that DHS may, in turn, provide potential applicants with guidance regarding the submission of an Application for SAFETY Act Designation. The Pre-Application Consultation is also intended to facilitate discussions regarding the SAFETY Act Application process. A Pre- Application Consultation is not a prerequisite for submitting a full application for SAFETY Act Designation.

(Pre-Application Consultation Request Form on following page)

Privacy Act Notice: DHS Authority to Collect This Information: 6 U.S.C. §§ 441–444 (the “SAFETY Act”) and 6 C.F.R. Part 25, 71 Fed. Reg. 33147, 33159. Principal Purposes: DHS collects telephone numbers, addresses, and other identifying information for the purpose of contacting individuals seeking liability protections on issues related to the SAFETY ACT application process. Routine Uses and Sharing: In general, DHS will not use this information for any purpose other than DHS personnel contacting the individual. However, DHS may release this information of an individual on a case-by-case basis as described in the S&T SAFETY Act System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure: Submission of this information is voluntary and an individual may opt not to provide the requested information or to provide only some of the information DHS requests. If an individual chooses to opt not to provide some or all of the requested information, DHS may not be able to process the individual’s request.

PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1640- 0001 and this form will expire on 03/31/2013. The estimated average time to complete this form is 1 hour per respondent. If you have any comments regarding the burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC 20528.

REQUEST FOR PRE-APPLICATION CONSULTATION

SELLER INFORMATION

P1. Seller Name:

P1.1. Description of Seller. Please provide an overview of your company, including place of incorporation and major affiliates or subsidiaries.

P2. Non-proprietary Summary

P2.1. Name of your Technology:

P2.2. Technology Description. Provide a non-proprietary overview of your Technology.

P3. Detailed description of your Technology. In an attachment, please provide a detailed description of your Technology and summarize your Technology’s qualifications for SAFETY Act Designation.

P4. Past and anticipated sales. Note: It may be very important and could significantly expedite your eventual application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental entity.

Who has purchased, utilized or plans to purchase your Technology? (Choose all that apply.)

Federal government (Agency: Approximate Date: ) State government (State: Approximate Date: ) Local government (City/County: Approximate Date: ) Commercial organization (Name: Approximate Date: ) Foreign government (Name: Approximate Date: ) Other (Name: Approximate Date: )

P5. Readiness for Sale. If your Technology has not previously been sold, provide an estimate of when it will be available for sale.

Immediately available for sale

Expected to be available for sales within months. (Fill in the blank.)

P6. Effectiveness

How do you know that your Technology is effective? What kinds of deployment information, test results, independent studies, or other corroborative information could you provide as part of a full Application to support the utility and effectiveness of your Technology? In an attachment, provide a summary of the available information supporting the safety and effectiveness of your Technology. Please indicate any deployments for military or governmental customers. It may be very important and could significantly expedite your eventual application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental entity.

P7. Liability Considerations

In an attachment, please identify the types of potential terrorist activity the Technology is intended to counter. Please describe, to the extent practicable, the scope of damage, loss of life, or other harm that could result from such terrorist activity. Please describe how the Technology has been deployed to date or will be deployed in the future should SAFETY Act Designation be issued.

Instructions for Completing Pre-Application Consultation Form:

Seller Information Item P1. Seller Name

Enter the legal name of your organization.

Item P1.1. Please provide a succinct description of your company. Please include the place of incorporation and any major affiliates or subsidiaries who will also be “sellers” of the technology. If your company web site or other publication provides this information, you may provide the web site locator or publication as a response to this question.

Item P2. Non-proprietary Summary

Item P2.1. Enter the name of your Technology.

Item P2.2. Please provide a succinct, non-proprietary description of your Technology. When describing your Technology, focus on providing information that will help the Department identify which subject matter technical expert evaluators would be best qualified to review your Technology.

One important purpose of this item is to help the Department recognize potential conflicts of interest and ensure that your application information is not disclosed to evaluators with potential conflicts of interest. The Department is committed to protecting your sensitive business data and may, upon request, describe its protocols for information protection.

Item P3. Description of your Technology

Include as an attachment to your application a summary of your Technology. This summary should be more detailed than your response to P2.2 and may include proprietary or sensitive information. Consider the following questions when preparing your response:

• What is your Technology? You may include information you provide to your customers when you sell that Technology.

• What is your Technology intended to do?

• What are its principal elements, systems, or components?

• How does it operate?

• How and where may it be utilized?

• If your Technology is a service, or incorporates a service, describe the actions, activities, planning, training, and/or expertise involved.

• What specific potential to counter terrorism does your Technology have? In particular, what sorts of terrorist attacks or attempted terrorist acts could be deterred, mitigated, or otherwise addressed by your Technology?

Item P4. Past sales

Who has previously purchased or utilized your Technology? What sales do you anticipate? When? Check and complete each line that applies.

Item P5. Readiness for Sale

Indicate how ready your Technology is to be sold by checking the appropriate box.

Item P6. Effectiveness

Include as an attachment to your application a summary of information available to demonstrate the usefulness and effectiveness of your Technology. The summary information you provide here should include information demonstrating your belief that your Technology can be a valuable counter terrorism tool. The kind of information your summary should include will depend on the nature of your Technology. Please indicate any deployments for military or governmental customers. It may be very important and could significantly expedite your eventual application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state or local governmental entity. Procurements of your Technology by a foreign government may also have significant relevance.

If your Technology is primarily a device or software product, your summary should briefly describe available developmental and operational test data that indicate the likely operating performance of that device or software. This could include performance in past deployments, independent test results, government licenses or certifications, field tests (e.g., performance against simulated attacks), internal test data, customer studies, scientific studies of the techniques involved, industry reports, government or military publications, or any other information that suggests or supports the potential usefulness of your Technology.

If your Technology is primarily a service, your summary should describe the nature and quality of the process or expertise involved and should include any available information of successful past deployments of a similar nature. Indicate whether those involved in providing the QATT have certain specialized training or certifications. In particular, you should also summarize available information that documents any of the following:

• The nature and quality of the services you provide.

• Your specification (or any governmental specification) for the processes used to provide those services. If formal protocol or processes exist, please describe them.

• Your methods for monitoring your adherence to your processes.

• Your means for measuring the success of a particular deployment of your services.

• Your expertise or reputation as a provider of these services.

• Compliance with standards from recognized standard setting organizations.

Item P7. Liability Considerations

In an attachment, please identify the types of potential terrorist activity the Technology is intended to address. Please describe, to the extent practicable, the scope of damage, loss of life, or other harm that could result from such terrorist activity. Please describe how your Technology has been deployed to date to counter this type of terrorism or will be deployed in the future should SAFETY Act Designation be issued. Please also describe how deployment of your Technology may be affected should your Technology not receive SAFETY Act Designation. Please include information relating to whether the timing of the deployment of your Technology will be affected.

You need not attach copies of any referenced reports, publications, or other information as part of this Pre-Application. However, be aware that such information should be provided as part of a full Application.

DHS Form 10009 (10/06)