Form DHS Form 9012 DHS Form 9012 Chemical-terrorism Vulnerability information Training &

CHEMICAL-TERRORISM VULNERABILITY INFORMATION (CVI) AUTHORIZATION INSTRUMENT

1. Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act, no one is required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) Control Number. The valid OMB Control Number for this information collection is 1670-0015. The time required to complete this information collection is estimated to average 0.50 hours 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.

2. Privacy Notice

Authority: 6 U.S.C. §§ 621-29 (Protecting and Securing Chemical Facilities from Terrorist Attacks Act of 2014, as amended) and the Chemical Facility Anti-Terrorism Standards, 6 C.F.R. Part 27 authorize the collection of this information.

Purpose: This collection is used to register respondents as a Chemical-terrorism Vulnerability Information (CVI) Authorized Users, issue unique CVI identification numbers, verify CVI Authorized User status, or contact respondents regarding their submission.

Routine Use: The Personally Identifiable Information (PII) you provide will be used by and disclosed to DHS personnel, contractors, or other agents, including but not limited to other Federal, state, and local officials; and used to contact the submitter and conduct any administrative follow up actions required to ensure compliance with the Chemical Facility Anti-Terrorism Standards.

Disclosure: Providing this information is voluntary. However, failure to provide any of the information requested may result in an individual not becoming a CVI Authorized User, not being able to verify CVI Authorized User status, or DHS not being able to contact respondents regarding their submission.

3. CHEMICAL-TERRORISM VULNERABILITY INFORMATION (CVI) AUTHORIZATION

This scope of this instrument includes an agreement to several affirmation statements and an application to become a CVI Authorized User. This instrument uses text fields and check boxes or similar means to collect the following information:

• Full Name (First, Last, MI)

• Organization Name

• Organization Type choose from one of nine categories:

  • Chemical facility employee

  • Chemical facility contractor

  • Vested private third party

  • DHS employee

  • Federal government employee

  • Federal government contractor

  • State or local government employee

  • State or local government contractor

  • Other (text box provided)

• Business Mailing Address (Street, City, State, Zip)

• Business Telephone Number (to include phone extension)

• Business E-mail

• Description of Respondent’s Official duties (narrative)

• Respondent’s Supervisor’s Name (First, Last, MI)

• Respondent’s Supervisor’s Telephone Number (to include phone extension)

In addition, this instrument uses check boxes to collect the following information:

• Acknowledgment that the respondent is familiar with all CVI requirements set forth in:

  • 6 U.S.C. § 623;

  • 6 CFR Part 27; and

• Any other requirements that may be officially communicated to the requester by DHS.

• Acknowledgment that the respondent is familiar with or has been provided access to the DHS Handbook entitled “Chemical-terrorism Vulnerability Information (CVI) Handbook.”

• Acknowledgment that if the respondent violates the requirements of 6 CFR Part 27.400, for protection of CVI, the respondent may be subject to civil penalties or other enforcement or corrective actions, by DHS, to include revocation of respondent’s CVI Authorized User status.