Copyright Release Form

Quadrennial Homeland Security Review (QHSR)

Copyright License Form

The Department of Homeland Security (DHS) is directed by the “Implementing Recommendations of the 9/11 Commission Act of 2007” to conduct a Quadrennial Homeland Security Review (QHSR) in fiscal year 2009 and every four years thereafter and report on the results of the first QHSR to Congress no later than December 31, 2009. The QHSR will describe overarching strategy and policy for the homeland security enterprise for the next four years.

Homeland security involves a distributed and decentralized network of Federal departments and agencies, State, local, and tribal governments, non-governmental organizations, communities, and citizens (collectively, the stakeholders). The input of this diverse stakeholder group will be an integral component of the review. As part of the stakeholder outreach, DHS is requesting its major stakeholder associations to submit recommendations, ideas, or positions papers addressing specified areas of study for the review. Stakeholders who are interested in submitting materials must complete this copyright license form to provide DHS the legal authority to reproduce, copy, display or prepare derivatives versions of the materials submitted.

Accordingly, I, ________________________, grant the United States of America, as represented by the Department of Homeland Security (DHS), permission to use materials I submit for the QHSR as described herein.

I grant to DHS and the Government of the United States of American or those acting on its behalf, a paid-up, nonexclusive, irrevocable, worldwide license in the materials submitted for the QHSR to reproduce, prepare derivative works, distribute copies to the public, and perform publicly and display publicly by or on behalf of the Government.

I hereby hold harmless the Government of the United States of America and those acting on its behalf for governmental purposes from any and all claims which arise out of or are in any way connected with such use of the materials, including any rights of privacy or publicity.

I acknowledge that I will not receive any compensation for the use of such materials.

I affirm that I am over eighteen (18) years of age and have the authority to grant this license.

I have read and understood this license and hold harmless agreement.

Signature:   ____________________ Date:

Signatory's Name:

Signatory's Position:

This form may digitally signed as shown in the example below:

Signature: /john smith/   Date: 05/20/2009
Signatory's Name: John Smith
Signatory's Position: Attorney of record

Privacy Act Statement

Authority:  Implementing Recommendations of the 9/11 Commission Act of 2007, (the “9/11 Act”), Pub. L. No. 110-53, 121 Stat. 266, 543, section 2401, (Aug. 3, 2007).

Principal Purpose: The Department of Homeland Security (DHS) will use this information as stakeholder source material for purposes of conducting the Quadrennial Homeland Security Review (QHSR) required by the 9/11 Act.

Routine Uses: This information will primarily be used by DHS as source material for the QHSR or other DHS purpose, and may be disclosed to the Government Printing Office or other publishing offices for production of a final document; to the news media and the public, unless it is determined that release of the specific information would constitute an unwarranted invasion of personal privacy; to the Department of Justice for the purpose of representing DHS or any officer, employee, or member of the Department in pending or potential litigation to which the record is relevant and necessary to the litigation; to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the request of that individual; to the National Archives and Records Administration for records management inspections conducted under the authority of 44 U.S.C. §§ 2904 and 2906; to contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government, when necessary to complete an agency function related to this system of records; and to the National Archives and/or other government libraries in order to respond to inquiries about DHS.

Disclosure: Voluntary; however, failure to provide the requested information may preclude participation in the QHSR process.