Form DHS Form 9036 DHS Form 9036 Request for An Extension

Request for Extension Instrument

For inclusion within ICR 1670-0014

Cybersecurity and Infrastructure Security Agency

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 1670-0014. The time required to complete this information collection is estimated to average 0.08 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.

Privacy Notice

Authority: The Protecting and Securing Chemical Facilities from Terrorist Attacks Act of 2014, Pub. L. No. 113-254 which is also codified at 6 U.S.C. § 621 et seq., as amended by Pub. L. No. 116-136, Sec. 16007 (2020) and the Chemical Facility Anti-Terrorism Standards (CFATS), 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 for an extension to its’ CFATS regulatory requirements. This information may also be required in order to contact the facility, if necessary.

Routine Uses: This information will be used by and disclosed to Department of Homeland Security (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 CISA may not be able to fulfill the request or contact you.

Basic Reporting Fields

CISA may collect the following basic information:

• Identification of CVI Authorized User status

• Submitter’s CVI Authorized User Status Number

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

• Phone Number of the Submitter

• Facility Name

• CSAT Facility ID #

• Facility's Address (Street, City, State, Zip)

• Date Submitted

Request for Extension

In this section, the instrument will collect the following information when a facility requests an extension for any of the following CFATS regulatory requirements:

• Which regulatory reporting requirement (e.g., Top-Screen, Security Vulnerability Assessment/Site Security Plan, other);

• Justification for the request (narrative);

• Proposed new due date for the selected report (month, day, year);

• Purpose of the request (narrative);

• Desired outcome of the request (narrative).

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