Form DHS 9500 DHS 9500 Filter Holder Log

Department of Homeland Security
Office of Health Affairs/BioWatch
Systems Program Office

OMB Control Number: 1601 – New
Expiration Date: mm/dd/yyyy

DHS Form 9500 (5/07)
Please read the instructions on the reverse before completing this log. For additional logs or assistance in completing this log, contact DHS
Chem/Bio Systems Program Office.

Instructions For Completing Filter Holder Log
PRINCIPAL PURPOSE: The purpose of this log is to support daily operations of the Department of Homeland Security’s (DHS) BioWatch Program.
The log is required to create a unique written chain-of-custody record tied to each collected filter sample to support law enforcement activities, including criminal
prosecution in the case of a deliberate release of a biological warfare agent.
Blocks:
Complete the requested information for each block by filling in all entry blanks. In the Comments/Field flags block, the field operator is able to write any additional
comments or observations made during the filter removal/installation process. Be as specific as possible when completing this log. Please write legibly.
Boxes:
Place a check mark in the appropriate box to identify the type of collector being serviced. All other boxes require a check mark when the corresponding action is
completed or as a requested observation is validated.
Paperwork Reduction Act Statement: The public reporting burden to complete this information collection is estimated at 1 minute per respondent, including the time
for reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collected 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 and expiration date. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHS, Office of Health Affairs,
Chem/Bio Early Detection Division, Washington, D.C. 20528: ATTN: PRA (1601-NEW).