Form 11000-29 Background Check to Identify Terrorist Ties for an Affec

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

Background Check to Identify Terrorist Ties for an Affected Individual
at a High Risk Chemical Facility
Section A: Full Name / Aliases of Affected Individual
1a. Last Name

1b. First Name

1c. Middle Name

1d. Suffix

Section B: Date & Place of Birth of Affected individual
2. Date of Birth

3a. City of Birth

3b. County of Birth

3c. State of Birth

3d. Country of Birth

Section C: Physical Description of Affected individual
4. Gender

Section D: Citizenship of Affected Individual
Citizenship

Passport Information (For Non-U.S. Citizens)

5. Country

6a. Passport Number

6b. Issuing Country

7. Alien Registration Number (For Non-U.S. Citizens)

Section E: Redress Number of Affected Individual
8. Redress Number issued to ensure an individual is no longer incorrectly matched against a known or suspected terrorist on the TSDB.

DHS Form 11000-29 (04/11)

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

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Section F: Other DHS Screening Programs
Number Issued by Other DHS Screening Program
9a. TWIC Number of Affected Individual

9d. FAST Number of Affected Individual

9b. Commercial Driver's License Number with a Hazardous
Material Endorsement (HME) of Affected Individual

9e. SENTRI Number of Affected Individual

9c. NEXUS Number of Affected Individual

Verifying Information
9f. Name(s) Enrolled Under With Other DHS Screening Program

9g. Expiration Date

9h. Other Program Specific Information Necessary to Verify Program Enrollment And Status

Section G: Additional Information about Affected Individual
10. Additional information necessary to determine if the affected individual is or is not a match to the Terrorist Screening Database (TSDB).

Section H: High-Risk Chemical Facility Association
11. Name(s) of High-Risk Chemical Facility

12. Unique Facility Identifier (e.g., CSAT Facility ID#)

Section I: Notification the Individual Is No Longer An Affected Individual
13. Indicate when the affected individual no longer has or is seeking access to restricted areas or critical assets

Section J: CFATS Personnel Surety POC Contact Information
14a. Contact Information Has Already Been Collected by DHS Through CFATS
CSAT User

CVI Authorized User

SSP Facility Security Officer

Other

Information Necessary To Verify

DHS Form 11000-29 (04/11)

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

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14b. Contact Information Has Not Been Previously Collected by DHS Through CFATS
Name

Title / Position

Phone Number

E-Mail

Other

Section K: Certification & Affirmation Statements by High-Risk Chemical Facility
Affirmation of Information Veracity
I affirm that, to the best of my knowledge, the information I am about to submit is true, complete, and correct. I understand that making
knowing or willful false statements to the federal government as a part of this information submission is prohibited by federal law.

Affirmation of SSP Compliance
I affirm that, to the best of my knowledge, the collection and submission to the Department of Homeland Security of this information is in
compliance with a high-risk chemical facility's Site Security Plan, as authorized or approved under 6 CFR Part 27.

Affirmation of Privacy Act Notice
I affirm that notice has been provided to the affected individuals whose information is being submitted which: (1) notifies those individuals
that their information is being submitted to DHS for vetting against the Terrorist Screening Database, and that in some cases additional
information may be requested and submitted in order to resolve a potential match; (2) instructs those individuals how to access their
information; (3) instructs those individuals how to correct their information; and (4) instructs those individuals on procedures available to
them for redress if they believe their information has been improperly matched by the Department of Homeland Security to information
contained in the Terrorist Screening Database.

FORM INSTRUCTIONS
WHEN TO FILE: A high-risk chemical facility should submit the information in compliance with a DHS approved schedule.
WHERE TO FILE: A high-risk chemical facility must submit the information through the Chemical Security Assessment Tool
(CSAT) unless requested to submit by DHS specific information otherwise.

PRIVACY ACT STATEMENT
AUTHORITY: This information collection is authorized by Section 550 of Public Law 109-295 and implementing
regulations, 6 CFR Part 27.
PURPOSE: This information is being collected to enable high-risk chemical facilities to fulfill the Personnel Surety Risk
Based Performance Standard (RBPS) in their Site Security Plans (SSPs). RBPS 12 at 6 CFR Part 27.230
(a)(12)(iv) requires that regulated high-risk chemical facilities implement “measures designed to identify
people with terrorist ties.”
ROUTINE USES: The information collected may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy
Act of 1974, as amended. This includes using the information, as necessary and authorized by the routine
uses published in NPPD/002 Chemical Facility Anti-Terrorism Standards Personnel Surety Program System
of Records.
DISCLOSURE: Furnishing this information is required pursuant to Section 550 of Public Law 109-295
and implementing regulations, 6 CFR Part 27.

PAPER WORK 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 0.54 hours (32.4 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 11000-29 (04/11)

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

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Expiration Date: XX/XX/XX

INSTRUCTIONS
General

This form should be used by the submitter of record for a CFATS covered facility to submit information to the Department in
compliance with 6 CFR 27.230(a)12(iv).

Question 1

Please enter the individual's first, middle, and last name (and/or aliases).

Question 2

Please enter the individual's date of birth.

Question 3

Please enter the individual's place of birth.

Question 4

Please select the individual's gender.

Question 5

Please enter the affected individual's citizenship.

Question 6

Please enter the affected individual's passport information. Multiple passports may be entered.

Question 7

Please enter the affected individual's alien registration number.

Question 8

Please enter the affected individual's Redress Number Issued by DHS.

Question 9

Please enter the affected individual's information necessary to confirm the affected individual's enrollment and status in
another DHS Screening Program.

Question 10

This information is not routinely collected through the IT system. In certain cases, DHS may be required to collect
additional information (e.g., visa information) about affected individuals in order to clarify data errors or to resolve potential
matches (e.g., in situations where an affected individual has a common name). Such requests will not imply, and should
not be construed to indicate, that an individual has been confirmed as a match to the TSDB.

Question 11

Please enter the name(s) of the high-risk chemical facility at which the affected individual has access to a restricted area or
critical asset.

Question 12

Please provide any unique identifying information of the high-risk chemical facility (e.g., CSAT Facility ID #).

Question 13

Please enter when the affected individual no longer has or is seeking access to a restricted area or critical asset.

Question 14

Please provide contact information for the appropriate individual that can respond to questions about the affected
individual.

DHS Form 11000-29 (04/11)

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

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