Form DHS Form 9034 DHS Form 9034 Request for Technical Consultation

OMB No. 1670-NEW
Expiration Date: XX/XX/XX
DEPARTMENT OF HOMELAND SECURITY

REQUEST FOR TECHNICAL CONSULTATION
Contact Information Submitting Request:
1a) Is the Submitter a CVI Authorized User?
Yes

No

1b) If yes, provide CVI Authorization Number of Submitter:

CVI -

2) Name of the Submitter: (Last, First, MI)

3) Phone Number of the Submitter:

4a) CSAT Facility ID #

4b) Facility Name:

5a) Facility's Street Address:

5b) City, State, Zip Code

6) Date Submitted

Technical Consultation Request:
6) Name and CVI Authorization # of individual to attend consultation:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number

Name:

CVI Authorization Number

7) Reason for Request:

I request a technical consultation regarding the modification of my facility.
I request a technical consultation regarding the modification of my facility's processes.
I request a technical consultation regarding the modification of the types of materials that my facility possesses.
I request a technical consultation regarding the modification of the quantities of materials that it possesses.
Other:
8) Explanation for Request:

9) Desired Outcome for
Request:

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

DHS Form 9034 (4/09)

OMB No. 1670-NEW
Expiration Date: XX/XX/XX
REQUEST FOR TECHNICAL CONSULTATION FORM INSTRUCTIONS

DHS FORM 9034, REQUEST FOR TECHNICAL CONSULTATION
(Read the following instructions carefully before you complete this form.)

GENERAL:
1.

This form should be used when a covered facility seeks a consultation and/or technical assistance.

Indicate the submitter's CVI number on the form. If you do not know if the submitter is a CVI Authorized
user, please contact the help desk for assistance.

2.

Please provide the name of the submitter. This name should be the name submitted during the registration process.

3.

Please provide a phone number where the submitter can be reached at. When providing the phone
number, only input numeral digits into the given space. This number should be the number submitted during the
registration process.

4.

Please provide the name of the facility and the CSAT facility's ID number. If you do not know the
CSAT facilities ID number, please contact the help desk.

5.

Please provide the full physical address of the covered facility.

6.

Please enter the date this form is being submitted.

7.

Please provide the names and CVI Authorization Numbers of those who will attend the consultation meeting.

8.

Please check the box that best describes the reason for your request for this technical consultation.

9.

Please provide a detailed explanation for this request for technical consultation.

9.

Please provide a detailed description of the desired outcome for this request.

WHEN TO FILE: In accordance to 6 CFR Part 27.120, when a facility seeks consultation or technical assistance
they will need to fill in this form and submit it to DHS.
WHERE TO FILE: DHS Form 9034 for Requesting a Technical Consultation may be submitted to DHS.through the
Chemical Security Assessment Tool (CSAT). Keep a copy of the completed form for your records.

PRIVACY ACT STATEMENT
1.

FORM/TITLE: Department of Homeland Security (DHS) DHS Form 9034, Request a Technical Consultation with
the Department of Homeland Security.

2.

AUTHORITY: Section 550 (c) of Public Law 109-295 entitled, Making Appropriations of the Department of
Homeland Security for the Fiscal Year Ending September 30, 2007, and for other purposes (October 4, 2006),
directs DHS to protect from public disclosure "information developed under [Section 550], including vulnerability
assessments... and other security related information records and documents..." As required by Section 550,
DHS Promulgated CFATS as an interim final rule in April 2007. See 6 CFR Part 27; 72 Fed. Reg. 17688

3.

BURDEN STATEMENT: The public reporting burden for the Request for Technical Consultation report is
estimated to be 15 minutes. The burden estimate includes time for reviewing instructions, researching the
situation, 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:
NPPD / IP / Infrastructure Security Compliance Division
Attention: CFATS Project Manager
U.S. Department of Homeland Security
Mail Stop 8100
Washington, DC 20528-8100

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 15 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 9034 (4/09)