Form 10061 (04/10) 10061 (04/10) Notice of Data Access Expiration

DHS PREDICT Notice of Data Access Expiration

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: TBD (Three years from approval date)

5. Agency Form Number: DHS Form 10061 (04/10)

6. Name of Form: Notice of Data Access Expiration

7. Purpose of Form: To alert users that access to data is expiring and to allow users to apply for extensions.

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 Data Access Expiration

Reference Issue #:

Dear ________________:

This document is used by the PREDICT Coordinating Center (PCC) to notify a Researcher/User that their Memorandum of Agreement (MOA) and access to approved Datasets is about to expire and to ask whether they would like to extend the MOA and access to approved Datasets for an additional 180 days.

Our records indicate that your MOA, MOA ID ___________, between _________________ and the PCC, and authorization to use the PREDICT datasets listed below will expire on _____________:

Please check the appropriate box:

____ I would like to request an amendment to the MOA to extend access to the approved datasets for an additional 180 days. This notice must be returned to the PCC at least seven (7) working days before the expiration of the existing MOA, as noted above.

_____ I do not need to extend access to the approved datasets.

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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