Form DHS Form 9025 DHS Form 9025 Tracking Log for Chemical-terrorism Vulnerability Inform

OMB No. 1670-NEW
Expiration Date: XX/XX/XX

DEPARTMENT OF HOMELAND SECURITY

Tracking Log for Chemical-terrorism Vulnerability Information (CVI)

CVI Authorized User Tracking Log
Last Name

Date Shared

DHS Form 9025 rev (9/09)

First Name

Description of CVI

Access, Disclosure or Both

CVI Authorized User Number

Name of Individual to
whom CVI is Shared

Recipients's CVI Authorized
User Number

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

Method of Sharing

OMB No. 1670-NEW
Expiration Date: XX/XX/XX

Date Shared

DHS Form 9025 rev (9/09)

Description of CVI

Access, Disclosure or Both

Name of Individual to
whom CVI is Shared

Recipients's CVI
Authorized User No.

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

Method of Sharing

OMB No. 1670-NEW
Expiration Date: XX/XX/XX

FORM INSTRUCTIONS
WHEN TO FILE: A CVI authorized user may use this log to record information on CVI sharing.

WHERE TO FILE: There is no requirement to submit or maintain this record. However DHS encourages all CVI authorized users to maintain a CVI tracking log.

PRIVACY ACT STATEMENT
1.

Authority: Section 550 (c) of Public Law 109-295 and implementing regulations, 6 CFR Part 27.

2.

Purpose: To track the sharing, access and disclosure of CVI.

3.

Routine Uses: The Personal Identifiable Information (PII) will be used by and disclosed pursuant to a published Privacy Act System of Records Notice. the

4.

Disclosure: Furnishing this information is voluntary pursuant to Section 550 (c) of Public Law 109-295 and implementing regulations, 6 CFR Part 27.

Chemical Facility Anti-Terrorism Standards (CFATS) PII is collected under the General Information Technology Access Account Records System (GITAARS)
http://edocket.access.gpo.gov/2008/E8-10895.htm DHS/ALL-004

PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act, no one is required to respond to a collection of information unless it displays a valid OMB Control Number. The valid
OMB Control Number for this information collection is 1670-NEW. The time required to complete this information collection is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.

DHS Form 9025 rev (9/09)

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

OMB No. 1670-NEW
Expiration Date: XX/XX/XX

Instructions for Tracking Log for Chemical-terrorism Vulnerability Information (CVI)

Please enter the full name and CVI Authorized User number of the CVI Tracking Log owner.

Date Shared

Description of CVI

Please indicate the date shared.

Please provide a short description of the CVI. Do not disclose CVI information in your description.

Access, Disclosure or Both Using the drop down menu provided, please indicate if the CVI was accessed, disclosed or both.
Name of Individual to whom
Please enter the full name of the individual to whom the CVI was shared.
CVI is Shared
Recipients's CVI Authorized
Please enter the recipient's CVI Authorized user number using the following format yyyymmdd-xxxxxxx.
User No.
Method of Sharing

DHS Form 9025 rev (9/09)

Using the drop down menu provided, please indicate the method used to share the CVI, e.g. email, verbal, mailed, faxed or other.

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays