Form DHS Form 9034 DHS Form 9034 Request for Technical Consultation

OMB No. 1670-0014
Expiration Date: March 13, 2013
DEPARTMENT OF HOMELAND SECURITY

REQUEST FOR TECHNICAL CONSULTATION
Contact Information Submitting Request:
1a) Is the Submitter a CVI Authorized User?
Yes

No

1b) If yes, provide CVI Authorization Number of Submitter:

CVI -

2) Name of the Submitter: (Last, First, MI)

3) Phone Number of the Submitter:

4a) CSAT Facility ID #

4b) Facility Name:

5a) Facility's Street Address:

5b) City, State, Zip Code

6) Date Submitted

Technical Consultation Request:
6) Name and CVI Authorization # of individual to attend consultation:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number:

Name:

CVI Authorization Number

Name:

CVI Authorization Number

7) Reason for Request:

I request a technical consultation regarding the modification of my facility.
I request a technical consultation regarding the modification of my facility's processes.
I request a technical consultation regarding the modification of the types of materials that my facility possesses.
I request a technical consultation regarding the modification of the quantities of materials that it possesses.
Other:
8) Explanation for Request:

9) Desired Outcome for
Request:

DHS Form 9034 (4/09)

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

OMB No. 1670-0014
Expiration Date: March 13, 2013
REQUEST FOR TECHNICAL CONSULTATION FORM INSTRUCTIONS

DHS FORM 9034, REQUEST FOR TECHNICAL CONSULTATION
(Read the following instructions carefully before you complete this form.)

GENERAL:
1.
2.

This form should be used when a covered facility seeks a consultation and/or technical assistance.

Indicate the submitter's CVI number on the form. If you do not know if the submitter is a CVI Authorized
user, please contact the help desk for assistance.
Please provide the name of the submitter. This name should be the name submitted during the registration process.

3.

Please provide a phone number where the submitter can be reached at. When providing the phone
number, only input numeral digits into the given space. This number should be the number submitted during the
registration process.

4.

Please provide the name of the facility and the CSAT facility's ID number. If you do not know the
CSAT facilities ID number, please contact the help desk.

5.

Please provide the full physical address of the covered facility.

6.

Please enter the date this form is being submitted.

7.

Please provide the names and CVI Authorization Numbers of those who will attend the consultation meeting.

8.

Please check the box that best describes the reason for your request for this technical consultation.

9.

Please provide a detailed explanation for this request for technical consultation.

9.

Please provide a detailed description of the desired outcome for this request.

WHEN TO FILE: In accordance to 6 CFR Part 27.120, when a facility seeks consultation or technical assistance
they will need to fill in this form and submit it to DHS.
WHERE TO FILE: DHS Form 9034 for Requesting a Technical Consultation may be submitted to DHS.through the
Chemical Security Assessment Tool (CSAT). Keep a copy of the completed form for your records.

PRIVACY NOTICE
Authority: Section 550 of the Department of Homeland Security Appropriations Act of 2007, Pub. L. No. 109-295 and
implementing regulations, the Chemical Facility Anti-Terrorism Standards, 6 C.F.R. Part 27 authorize the collection of this
information.
Purpose: The primary purpose of this collection is to obtain information regarding a facility's request, including the submitter's
contact information.
Routine Uses: This information will be used by and disclosed to DHS personnel, contractors, or other agents to assist in
fulfilling the request and contacting the submitter, if necessary.
Disclosure: Providing this information is voluntary. If you choose not to provide this information, then DHS may not be able to
fulfill the request or contact you.

OMB 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 1670-0014. The
time required to complete this information collection is estimated to average 15 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 9034 (4/09)