Critical Infrastructure Workers Denied Movement Reporting_Form

OMB No: 1670-New
Expires: xx//xx/xxxx

CISA Situation Reporting System –

Critical InfrastructureWorkers Denied Movement Report
The CISA Situation Reporting System provides a secure web-enabled means of reporting Critical Infrastructure Workers Denied
Movement situations to CISA. This system assists analysts in providing timely handling of your reports as well as the ability to conduct
improved analysis and advocate for change. If you would like to report a Critical Infrastructure Workers Denied Movement situation,
please complete the following form. Please provide as much information as you can to answer the following questions to allow CISA to
understand your situation.

What Is a Reportable Situation?
For the purposes of this system, a Critical Infrastructure Workers Denied Movement situation occurs anytime an individual or entity
believes they are considered an essential worker under the local definition and was denied the ability to move around to conduct
activities the local authorities have determined are authorized.
Disagreements with local restrictions should not be reported in this manner.
We encourage you to report any activities that you feel meet the definition of a Critical Infrastructure Workers Denied Movement
situation via this system.

Using the CISA Situation Reporting System
In order for us to respond appropriately, please answer the questions as completely and accurately as possible. Questions that must be
answered are marked with a red asterisk.
Please refrain from including PII or SPII unless the information is necessary to understanding the nature of the Critical Infrastructure
Workers Denied Movement.

Choice:

Choose an option

Name:

First Name

Phone:

Phone Number

Email:*

Email

Individual
Affected:

First Name

Last Name

Last Name

What Essential Worker category do you belong to?
Critical Manufacturing

Date of Encounter?:*

Time

Approximate Time Situation Occurred:*

Location of the Encounter:

City

Choose one

Details of the Encounter:

Write details here...

Name/address of Destination:

Was access letter presented?:

Entity that prohibited access?:

Facility Name

Yes

No

Agency Name

Privacy Act Statement
A u t h o r i t y : 5 U.S.C.§301 and 44 U.S.C.§3101 authorize the collection of this information.
P u r p o s e : The primary purpose for the collection of this information is to allow the Department of Homeland Security to contact you about your request.
R o u t i n e U s e s : The information collected may be disclosed as generally permitted under5 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 DHS/ALL-002-Department of Homeland Security(DHS) Mailing and OtherLists System November
25, 2008,73FR71659.
D i s c l o s u r e : Providing this information is voluntary. However, failure to provide this information will prevent DHS from contacting you in the event there are questions
about your request.
Paperwork Reduction Act Statement
The public reporting burden to complete this information collection is estimated at 5 minutes per response,including the time for reviewing instructions, searching
existing data sources,gathering and maintaining the data needed, and the completing and reviewing the collected information. The collection of information is voluntary.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number
and OMB expiration date. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to CISA IOD, CISA Agency Stop 0380,DHS, 245 Murray Lane,Washington,D.C. 20528-0380, ATTN: PRA [OMB Control No. 1670-NEW].