Request for Determination of CVI Instrument Scope

Determination of CVI Instrument

Name of Instrument

Determination of CVI

Scope of Instrument

This instrument collects:

• Personally identifiable information from the individual submitting request

• Relevant facility information

• Relevant information necessary to determinate if the information is CVI

Example of DHS Forms used within the scope of this instrument

Attached is DHS Form 9028 that is used to standardize the collection of information within this instrument. DHS Form 9028 identifies most, but not all of the data routinely collected under this instrument.

1