Appendix A Please read Privacy Act Statement and instructions on reverse before completing this form.

United States Environmental Protection Agency

Washington, DC 20460

TSCA CBI Access Request, Agreement, and Approval 

Section I. – Access Request

1. Name (Last, First, MI) 2. 9-Digit ID Number (e.g., SSN) 3. Telephone Number

4. Requestor (Agency/Office/Division/Branch) 5. Document Control Officer (DCO) 6. DCO Telephone Number

7.TSCA Sections for which access is 

 required. Check all that apply. Use blank ALL _____ - OR- 4 ___ 5 ___ 6 ___ 8 ___ 12 ___ 13 ___ 21 ___ _________

 space to request other sections not listed. 

8. Justification for TSCA CBI access. Other 

 Select appropriate code from instructions on List Justification on reverse side

 reverse side. (Check one for all that apply). A ______ B ______ C ______ D ______ 

Section II. – Contract Information - Contractor Employees Only

9. Employer’s Name 10a. Employer’s Address 10b. City 10c. ST 10d. Zipcode

11. Contract Number 12. EPA Project Officer 13. EPA Project Officer Telephone

Section III. – OPPT Secure Storage Area Access – HQ Federal and HQ Contractor Employees Only

14. Check if EPA ID Badge. Badge is required.

Yes (New) Need Replacement No (List Present EPA ID Badge Number ___________________________) 

15. List OPPT Restricted areas by Division to which physical access is required.

Home Division (24 hour access) Other Divisions (6A.M. – 6P.M. only) Access to CBIC Only IMD (DCO and IMD Computer Rms.)

16. List OPPT areas by Division and Room Number for which Alarm Activation/Deactivation Authority is requested. 

Section IV. – Confidentiality Agreement

I understand that I will have access to certain Confidential Business Information submitted under the Toxic Substances Control Act (TSCA, 15 USC 2601 et seq.). This access has been granted in accordance with 

my official duties relating to Environmental Protection Agency programs. 

I understand that TSCA CBI may be used only in connection with my official duties and may not be disclosed except as authorized by TSCA and Agency regulations. I have received a copy of, and understand the 

procedures set forth in, the TSCA CBI Protection Manual. I agree that I will treat any TSCA CBI furnished to me as confidential and that I will follow these procedures.

I understand that under section 14(d) of TSCA (15 USC 2513(d)), I am liable for a possible fine of up to $5,000 and/or imprisonment for up to one year if I willfully disclose TSCA CBI to any person not authorized to 

receive it. In addition, I understand that I may be subject to disciplinary action for violation of this agreement with penalties ranging up to and including dismissal. 

I understand that my obligation to protect TSCA CBI, which has been disclosed to me as part of my official job duties, continues after either termination of my assignment or termination of my employment.

I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any knowingly false or misleading statement may be punishable by fine or

imprisonment or both under applicable law. 

17. Signature of Employee 18. Date

Section V. – Requesting Official Approval

20. Name and Signature of Requesting Official. (Immediate Supervisor – EPA Project Officer for Contractors) As the 

immediate supervisor of (or the EPA Project Officer for) the above mentioned employee, I certify he/she has successfully 

completed a TSCA CBI Security Briefing on the date shown.

19. TSCA CBI Security Briefing Date

Name Signature 21. Date

22. Date Received 23. Approved (TSCA Security Official Signature) 24. Approval Date

DCO Code Barcode Status Code Alarm Zones Data Entry Date and Initials

1. 2. 

EPA Form 7740-6 (Rev. 10-03). Replaces previous version of 7740-6 and 7740-6A.
Paperwork Reduction Act Notice

 The public reporting burden for the collection of information is estimated to average .84 hours per response. This estimate includes time for 

reviewing instructions, gathering and maintaining the needed data, and completing and reviewing the collection of information. Send comments 

regarding the burden estimate or any other aspect of this collection of information to the Director, Collection Strategies Division, US Environmental

Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington DC 20460, and to the Office of Information and Regulatory Affairs, Office of 

Management and Budget, Washington, DC 20503, marked ATTENTION: Desk Officer for EPA. Include the OMB No. identified on page 1 in any

correspondence. Do not send the completed form to this address. Submit the form in accordance with the instructions in the CBI Manual.

Privacy Act Statement

 Furnishing your Social Security Number is voluntary, but encouraged. The information on this form is used by EPA to maintain a record of 

those persons cleared for access to TSCA Confidential Business Information (CBI) and to maintain the security of TSCA CBI. 

 Disclosure of information from this form may be made to the Office of Pollution Prevention and Toxics (OPPT) contractors in order to carry out 

functions for EPA compatible with the purpose for which this information is collected; to other Federal agencies when they possess TSCA CBI and 

need to verify clearance to EPA and EPA contractor employees for access; to the Department of Justice when related to litigation or anticipated 

litigation involving the records or the subject matter of the records; to the appropriate Federal, State or local agency charged with enforcing a statute or 

regulation, violation of which is indicated by a record in this system; where necessary, to a State, Federal or local agency maintaining information 

pertinent to hiring, retention, or clearance of an employee, letting of a contract, or issuance of a grant or other magistrate or administrative tribunal; in 

the course of litigation under TSCA; and to a member of Congress acting on behalf of an individual to whom records in this system pertain.

Instructions for Form Completion

Section I – To be completed by all Section III – To be completed by HQ Federal 

and HQ Contractor employees only

1. List Full Name

2. List 9-Digit ID (e.g., SSN)

3. List Telephone number of person in item 1

4. List Full Acronym of Requesting Office (i.e. EPA Office in which the 

individual works or for contractor employees, the EPA Office with whom 

the contract is with)

5. List the immediate Document Control Officer for the office in which the 

individual works

6. List the telephone number of the Document Control Officer

7. Check the TSCA Sections for which access is requested or check ALL 

if applicable

8. Circle the appropriate Access Justification Code

 A. Employee is an EPA employee or EPA contractor employee whose 

work assignments involve the New and/or Existing Chemical Programs of 

TSCA. Hence access to the TSCA sections listed in item 7 of this form is 

required in performance of his/her duties.

 B. Employee is an EPA employee or EPA contractor employee whose 

work entails the administration of computer systems housing TSCA CBI. 

Hence access to the TSCA sections listed in

item 7 of this form is required.

 C. Employee is an EPA employee or EPA contractor employee whose 

work entails physical security or maintenance for TSCA CBI secure 

storage areas. Although employee will not actually

work with any TSCA CBI materials, access to the TSCA sections listed in 

item 7 of this form is required.

 D. List Justification here 

 

 

 

NOTE: These procedures apply only to employees requiring access to 

OPPT Secure Storage areas. All others follow standard Agency 

procedures.

14. Check either box a, b, c or (c&d) for EPA ID badge or Contractor 

Building Pass. If box c is checked, write in badge number.

a. Yes - Check if new employee getting first EPA ID Badge. (New 

programmed badge and barcode)

b. Need Replacement - Check if replacement ID Badge is needed 

(replacement badge and barcode)

c. No - Existing badge needs programming. List ID Badge no.

15. Check and list OPPT secured areas for which access (via “RUSCO” 

electronic door control system) is required. List Division acronyms for the 

requested areas.

Home Division - List Division in which employee works

Other Divisions - List other OPPT Divisions for which unrestricted 

daytime access is requested

CBIC Only - To be checked for those who only need to access the 

Confidential Business Information Center.

IMD Areas - Employees who need to regularly access the IMD Document 

Control Office Suite should circle DC0 in the fourth block. Only IMD staff 

and contractors who work in IMD computer rooms should circle IMD 

Computer Rooms.

16. List OPPT areas by Division and Room numbers for which Alarm 

Activation/Deactivation authority is requested. Generally, this is 

employees home Division only.

Section II – To be completed by Contractor 

Employees only

Section IV – To be completed by all

17. Employee Signature (must be original)

18. Signature Date

Section V – To be completed by all

19. Enter date employee attended TSCA CBI Security Briefing

20. Immediate Supervisor/EPA Project Officers name and sign.

21. Date of signature

Section VI – To be completed by OPPT Security

9. List Employer’s name 

10a-d. List Employer’s address

11. List Contract number

12. List EPA Project Officer’s name

13. List EPA Project Officer’s telephone number