1670-0019 Revised Instrument

1. Contact Us

U.S. Department of Homeland Security (DHS)

Cybersecurity and Infrastructure Security Agency (CISA)

Infrastructure Security Division

Office of Chemical Security

[email protected]

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*Your name:

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*Your email address:

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*Your message:

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2. Registration Information

[Dropdown Selection]

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[Open field]

[Dropdown selection]

[Open field]

[Open field]

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*Registration Type:

Personal Information

*First name:

*Last name:

*Email Address:

Job Title:

*Company:

Company Website:

*Company Country

*Company Zip/Postal Code:

*First time attending this event?

☐ Yes

☐ No

[Open field]

How did you hear of this [program/event]?

*Pursuant to the Americans with Disabilities Act, do you require any specific aids or services?

☐ Yes

☐ No

If yes, may we contact you directly to confirm that appropriate accommodations have been made?

☐ Yes

☐ No

*Please select the category to which your organization belongs:

Note: if you represent a Non-Governmental Organization or Non-Profit Organization, please select ‘Other’ and specify either NGO or NPO in the text field.

☐ Public Sector

☐ Private Sector

☐ International

☐ Other

[Open field]

If Public Sector:

☐Federal

☐ State

[Open field]

☐ Local

☐ Other

If Private Sector:

Please select the option that best describes your organization’s type:

☐ Academia

☐ Chemical End-user

☐ Chemical Manufacturing and Processing

☐ Chemical Storage, Stockpile, and Distribution

☐ Chemical Transport

☐ Industry Organization

☐ Non-Governmental Organization

☐ Non-Profit Organization

[Open field]

☐ Trade Organization

☐ Other

Please select the option that best describes your organization’s size:

☐ 1-49 employees

☐ 50-99 employees

☐ 100-499 employees

☐ 500+ employees

[Open field]

To which Trade Organizations, if any, does your organization belong?

Paperwork Reduction Act

The public reporting burden to complete this information collection is estimated at 3 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collected information. 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 expiration date. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHS/CISA/ISD/Chemical Security, [email protected], ATTN PRA OMB Control Number 1670-0019, expiration date August 31, 2026.

Privacy Act Statement

Authority: 5U.S.C.§301 and 44 U.S.C.§3101 authorize the collection of this information

Purpose: DHS will use this information to register individuals for chemical security events including the Chemical Security Summit, and to facilitate stakeholder outreach activities, including activities related to the ChemLock voluntary program

Routine Use: The information will be used by and disclosed to DHS personnel and contractors or other agents who need this information to assist in activities relating to registering or contacting individuals regarding chemical security event registration. This information may be disclosed as generally permitted under 5U.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 Other Lists System (November 25, 2008 73 FR 71659).

Disclosure: Furnishing this information is voluntary; however failure to provide any of the information requested may prevent or delay the Department from fulfilling your request.

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