Form 10041 (12/07) 10041 (12/07) Notice of Dataset Access/Application Expiration

DHS PREDICT Notice of Dataset/ Application Expiration Form

Cover Sheet

1. Department Name: Department of Homeland Security

2. Component/Agency Name: Science and Technology Directorate

3. OMB Control Number: 1640-0012

4. Expiration Date: 08/31/2010

5. Agency Form Number: DHS Form 10041 (12/07)

6. Name of Form: Notice of Dataset/ Application Expiration

7. Purpose of Form: To alert users that datasets/applications are expiring and allows users to apply for extensions or certify deletion of datasets.

8. How to submit: Sign and fax to the PREDICT Coordinating Center, RTI

International, Attn: Renee Karlsen, 866.835.0255 (toll free).

PREDICT

Notice of MOA & Data Request Extension

Reference Issue #:

Dear ______________________:

REGARDING: Your Dataset Request: __________________________________

Date of Request:____________________________

This document is used by the PREDICT Coordinating Center (PCC) to notify an approved Researcher/User of the PREDICT system that your request for the following datasets must be followed by a signed Memorandum of Agreement (MOA). The PCC sent you a MOA tailored to your dataset request via email on the date you submitted the request. This MOA must be completed and returned to the PCC within thirty (30) days of the date you received the email or you may request an extension of an additional 30 days to submit the MOA. If you request such an extension, your request for the datasets will remain pending for an additional thirty (30) days, until ________________. If the MOA has not been received by that date, the data request will be cancelled. You may apply again for access to these datasets.

Please check the appropriate choices:

____ I do not wish to submit an MOA for the requested datasets at this time, and my data request may be cancelled.

____ I would like an extension of an additional 30 days time to complete the MOA and submit it to the PCC.

____ I have some questions regarding completion of the MOA and would like PCC to contact me to assist me in completing my application.

Please fill in the information below and fax this document to the PREDICT Coordinating Center, RTI International, Attn: Renee Karlsen, at 866.835.0255 (toll free). Questions may be directed to Ms. Karlsen by telephone at (919) 541-7115 or via email at [email protected].

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