Form 10061 (4/10) 10061 (4/10) PREDICT Memorandum of Agreement / Data Extension

OMB # 1640-0012 / Expires 12/31/2013

PREDICT
NOTICE OF MOA & DATA ACCESS EXPIRATION

ID #:

Name of Research Project:

Dear ________________:
Our records indicate that the MOA between _________________ and the PREDICT Coordinating
Center (PCC) and the associated authorization to use the approved PREDICT datasets listed below will
expire on _____________. We are writing to ask if you would like to extend the MOA and access to
these Datasets for an additional 180 days. (See below)
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 contact information below and email or fax this document to [email protected]
or the PREDICT Coordinating Center, RTI International, Attn: Project Manager, at +1 866 835 0255
(toll free). Questions may be directed to the PCC by telephone at +1 800 957 6422 (USA) or via email.

DHS Authority to Collect This Information:  The Homeland Security Act of 2002 [Public Law 107‐296, §302(4)] authorizes the Science and Technology Directorate to conduct 
“basic and applied research, development, demonstration, testing, and evaluation activities that are relevant to any or all elements of the Department, through both intramural 
and extramural programs.” In exercising its responsibility under the Homeland Security Act, S&T is authorized to collect information, as appropriate, to support R&D related to 
improving the security of the homeland. Principal Purpose:  DHS collects name, organization and title (if any), email address, home and/or work address, and telephone 
numbers for the purpose of contacting individuals regarding the PREDICT project and/or their involvement with PREDICT. Routine Uses and Sharing:  Some of your information 
will be disclosed to PREDICT team members, such as data hosts, data providers, PREDICT contractors, the Predict Coordinating Center, the advisory board, and review board 
members to help us deliver requested PREDICT services and operate the PREDICT Web site and deliver the services you have requested. Unless you consent otherwise, this 
information will not be used for any purpose other than those stated above. However, DHS may release this information for an individual on a case‐by‐case basis as described in 
the DHS/ALL‐002 System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure:  Furnishing this information is entirely voluntary; however, failure 
to furnish at least the minimum information required to register (to include full name and email address,) will prevent you from obtaining authorization to access system.  

PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information collection unless it displays 
a current valid OMB control number and an expiration date. The control number for this collection is 1640‐0012 and this form will expire on 12/31/2013. The estimated average 
time to complete this form is 15 minutes per respondent. If you have any comments regarding the burden estimate you can write to Department of Homeland Security, Science 
and Technology Directorate, Washington, DC 20528. 

DHS Form 10061 (4/10)

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Last Update: 9-8-11-v8.0

Extend Access to These Datasets:
Provider

DHS Form 10061 (4/10)

Dataset Name

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Last Update: 9-8-11-v8.0

Contact Information
Name
Title
Organization
Address
City

State/Province

Postal Code/Zip

Country

Email

Phone

Alternate Phone

Fax

DHS Form 10061 (4/10)

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Last Update: 9-8-11-v8.0