D-11 DHS Form 200-2-ROS.pdf

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6.3.0.20170316.1.928536

REPORT OF SURVEY

DHS Form 200-2 (See instructions on reverse)

1. DHS Component Code

2. Component Program Area

3. Property Custodian First and Last Name:

Phone:

4. Report of Survey Number

5. Asset Type

6. Asset/Item Description

7. Manufacturer

8. Model Number

9. Barcode Number

10. Serial Number

11. Equipment Control Class (ECC)

12. Acquisition Value/Unit Cost

13. Acquisition Date

14. Was item lost, damaged, destroyed, or stolen?

15. Date Discovered

16. Date reported to Component property office

17. Date Report of Survey initiated

18. City and state where event occurred

19. Location where event occurred

20. Circumstances of loss

21. Does item/asset contain any sensitive, classified, or Personally Identifiable Information?

22. Police Report filed? If yes, provide NCIC Number NCIC Number:

23. Security Operations Center (SOC) or equivalent, notified?

24. Date DHS Personal Property notified if an ECC-1 asset

25. Signature of Responsible Individual Date

26. Signature of Property Custodian

DEPARTMENT OF HOMELAND SECURITY

REPORT OF SURVEY

DHS Form 200-2 (6/21) Email:

Date Signature Name and Title Date

28. Executive/Administrative Officer

27. Component Property Management: Recommended Action(If Other, please describe) This form replaces/supersedes all previous versions.

ASSET RECOVERY

ADMINISTRATIVE REVIEW OR BOARD OF SURVEY FOLLOW UP

35. Was the item/asset recovered?

If yes, provide date:

36. Who recovered the asset? If Other, please describe.

37. Was the asset put back into use?

38. Additional Comments

29. Date Administrative Review Occurred or or

30. Date Board of Survey Convened

31. Board of Survey Determination (If Other, please describe)

32. Board of Survey Recommended Action (If Personnel Action, Other; or Other selected, please describe)

33. Date Report of Survey Closed

34. Personal Property Management Staff DHS Form 200-2 (6/21) Signature Name and Title Date This form replaces/supersedes all previous versions.

Instructions for Completion of DHS Form 200-2 The Property Custodian (PC) is responsible for preparing or coordinating the preparation of Reports of Survey to document the circumstances of each incident.

Block 1:

Use dropdown menu to enter DHS Component Code Block 2:

Component Program Area is the area reporting property that was lost, stolen, damaged, or destroyed.

Block 3:

Property Custodian’s first and last name, and phone and/or email Block 4:

Report of Survey number Block 5:

Asset Type is the standard description assigned to the Asset Category for this item Block 6:

Asset Description is the standard description or official name of the asset as reflected in the recognized property system of record Block 7:

Manufacturer Block 8:

Model Number Block 9:

Barcode number of the asset Block 10:

Serial number of the asset Block 11:

Use dropdown to enter the Equipment Control Class (ECC) of the asset: ECC-1, ECC-2, ECC-3, or ECC-4 Block 12:

Acquisition Value/Unit Cost at time of purchase Block 13:

Enter Acquisition Date as MM/DD/YYYY Block 14:

Use dropdown to identify if item was lost, damaged, destroyed, stolen, or not in physical inventory Block 15:

Enter date loss discovered as MM/DD/YYYY Block 16:

Enter date reported to Component property office as MM/DD/YYYY Block 17:

Enter date Report of Survey initiated as MM/DD/YYYY Block 18:

Enter City and State where event occurred as city written out, and two-letter state abbreviation (e.g., Philadelphia PA) Block 19:

Use dropdown to enter where event occurred (residence, government-owned vehicle, personally-owned vehicle, office, public venue, other) Block 20:

Describe the circumstances of the loss Block 21:

Use check boxes to indicate whether item/asset contains sensitive, classified, or Personally Identifiable Information.

Block 22:

Use check boxes to respond yes or no to whether a police report was filed. If a police report was filed, please indicate the NCIC number.

Block 23:

Use check boxes to respond yes or no to whether the Security Operations Center (SOC) or equivalent was notified.

Block 24:

Enter the date DHS Personal Property was notified as MM/DD/YYYY in the case of the loss of an ECC-1 Block 25:

The individual responsible for the loss signs and dates as MM/DD/YYYY Block 26:

The Property Custodian (or equivalent) signs and dates as MM/DD/YYYY Block 27:

Use dropdown to enter the Component property management recommended action (Administrative Review, Refer to Board of Survey, Not Accountable, No Evidence of Negligence or Misconduct, or Other). If other is selected, please provide description.

Block 28:

Enter name and title of the Chief of Staff, Executive, or Administrative Officer closing the Report of Survey Enter signature and date as MM/DD/YYYY Block 29:

Use dropdown to enter N/A or the date the Administrative Review occurred Block 30:

Use dropdown to enter N/A or the date the Board of Survey met DHS Form 200-2 (6/21) Enter Name and Title of the property management staff member staff assigned to the incident Block 34:

Enter signature and date as MM/DD/YYYY Block 35:

Enter yes or no to whether the asset was recovered. If the asset was recovered, enter the date it was recovered as MM/DD/YYYY.

Block 36:

Use dropdown to enter who recovered the asset (Original Accountable User, Another User, Law Enforcement Agency, Other. If other is selected, please enter the entity that recovered the asset.

Block 37:

Respond yes or no to whether the asset was put back into use Block 38:

The additional comments field is an optional field for use by Components DHS Form 200-2 (6/21) Block 31:

Use dropdown to provide the determination of the Board of Survey (Program Deficiency, Negligence/Misconduct, Not Accountable, or Other. If Other is selected, provide description.

Block 32:

Use dropdown to enter the Board of Survey recommended action (Accident, no action; Disaster, no action; Disaster, procedure change; Accountable, personnel action, training; Accountable, personnel action, other). If other is selected, please describe the recommended action Block 33:

Enter date Report of Survey closed as MM/DD/YYYY