Form DHS Form 9037 DHS Form 9037 Request for Determination

Request for Redetermination 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 0.25 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 redetermination, including the submitter's contact information.

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:

• 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 Redetermination

In this section, the instrument will collect information to support the redetermination of a tiering determination. In many instances, the collection may be concurrent with a facility’s submission of a Top-Screen pursuant to 6 CFR § 27.210(d). The information may also be collected after reviewing a Top-Screen which reflects material modifications by the facility.

The reason for the redetermination:

• Due to material modification either to operations or site, which has a reduction in the quantity of one or more of the COI(s) since the previous submission.

• Due to material modification either to operations or site, which has eliminated of at least one COI, but not all of the COI(s) since the previous submission.

• Due to material modification either to operations or site, which has eliminated all COI(s) since the previous submission.

• Due to material modification either to operations or site, which has eliminated all COI(s) and the facility has closed.

• Other (The facility will provide a narrative).

Supporting documentation, as applicable, such as:

• Reason for request;

• Removal and/or reduction of COI quantity and/or concentration;

• Vendor(s) to whom the chemicals were shipped to (e.g., Name, Street, City, Zip, and Country);

• Receipt/receiving Location of COI(s) locations;

• Process changes (e.g. a description of the removal of the COI(s), receiving location of removed COI(s), description and documentation for permanent change of process, description of management controls of planned future inventory of COI(s), etc.);

• Description of closure, sale, and/or end of lease;

• Invoices/bills of laden/inventory control forms;

• MSDS/SDS and other product labels;

• Substitute chemical and/or process being used;

• Description of management controls for future quantities of COI(s);

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