DHS Form 9002.1 Chemical Security Assessment Tool (CSAT) Reviewer Regist

OMB No. 1670-0007
Expiration Date: May 31, 2011
DEPARTMENT OF HOMELAND SECURITY

Chemical Security Assessment Tool (CSAT)
Reviewer Registration
Please read the instructions carefully before completing this form. The instructions must be available during
completion of this form.
Section A: Facility Location Information
1. Facility ID Number

2. Facility Name

3. Physical Address Information
3b. City

3a. Physical Address

3e. Country

4a. Latitude

3d. Zip Code

3c. State

4b. Longitude

5. Additional non-street location information:

Section B: User Granting Access to Reviewer
6. CSAT Username

7. Job Title or Person Authorizing User Transfer

8a. First Name

8b. Last Name

8c. Middle Initial

Section C: User Information for Reviewer
9b. Last Name

9a. First Name

10a. Mailing Address

10b. City

11a. Phone Number

11b. Phone Extension

9c. Middle Initial

10c. State

10d. Zip Code

12. Email Address

13. Is the user a U.S. Citizen?

Yes

No

14. Is the user domiciled in the U.S.?

Yes

No

DHS Form 9002.1 (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

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OMB No. 1670-0007
Expiration Date: May 31, 2011

PRIVACY ACT STATEMENT
1.

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

2.

Purpose: The information provided on the form will be used to register a CSAT reviewer for a facility.

3.

Routine Uses: The Personal Identifiable Information will be used by and disclosed pursuant to a published Privacy

Act System of Records Notice. 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
4.

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

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 1670-0007.

INSTRUCTIONS
The instructions for completing this form can be found in the CSAT User Registration User Guide. The User Guide is
available at www.dhs.gov/chemicalsecurity.

DHS Form 9002.1 (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

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