Report of Potential Release of CVI Instrument Scope

Disclosure of CVI Instrument

Name of Instrument

Disclosure of CVI

Scope of Instrument

This instrument collects:

• Personally identifiable information from the individual submitting report

• Relevant facility information

• Relevant information of potential release of CVI

Example of DHS Forms used within the scope of this instrument

Attached is DHS Form 9027 that is used to standardize the collection of information within this instrument. DHS Form 9027 identifies most, but not all of the data routinely collected under this instrument.

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