No preview available
HomeMy WebLinkAboutC11-007 FEMA E902 Mitigation and Recovery Course Application DEPARTMENT OF HOMELAND SECURITY See Reverse for O.M.B. No. 1660 - 0100 FEDERAL EMERGENCY MANAGEMENT AGENCY Privacy Act Statement Expires August 31, 2013 GENERAL ADMISSIONS APPLICATION SECTION I - GENERAL INFORMATION 1. U.S. Citizen IX YES r NO If No, City and Country of Birth: 2. NAME (Last, First, Middle Initial, Suffix) 3. SOCIAL SECURITY NUMBER Smith, Barry J. 522 - 90 - 5106 4. HOME ADDRESS (Street, avenue, road no. /city or town, state, and zip code) 5. WORK PHONE NO. ( 970 ) 328 - 3545 P.O. Box 311 Gypsum, CO 81637 6. HOME PHONE NO. ( 970 ) 390 -5671 7. FAX NO. ( 970) 328 - 8694 8. E - MAIL ADDRESS: barry.smith @eaglecounty.us 9a. ENTER COURSE CODE AND TITLE: (If you wish to apply for more than one course, 9b. COURSE LOCATION 9c. DATES REQUESTED (Please give three choices) please attach a sheet of paper to this application) E901 IEMC /AII Hazards: Recovery and Mitigation lEmmitsburg July 25 - 28 10. COMPLETE THE ITEMS BELOW REGARDING THE PREREQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING INSTITUTION DEGREE /CERTIFICATE DATE EARNED COURSE /FIELD OF STUDY ' Colorado Mountain College Fire Science Degree June 1983 Fire Science 11. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE IN TRAINING? 17 NO r YES (If yes, describe & indicate any special assistance required on a separate sheet) SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION 12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED 12b. NFIRS # 13. CURRENT POSITION AND NUMBER OF YEARS Eagle County Emergency Management, P.O. Box 850, Eagle, CO 81631 (NFA STUDENTS IN POSITION ONLY) Emergency Management Director - 9 years 14. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YQUR ORGANIZATION 14 a. JURISDICTION 14 b. ORGANIZATION 15. CURRENT STATUS 1 • r STATEWIDE 4. r SPECIAL DISTRICT/TOWNSHIP 7 r FOREIGN 1. 17 ALL CAREER 1 Ix PAID FULL TIME 2. Ix' COUNTY GOVERNMENT 5. E FEDERAL/MILITARY (non -DHS) 8. r DHS/FEMA 2. E ALL VOLUNTEER 2. r PAID PART TIME 3. r CITY/TOWNNILLAGE 6. r INDUSTRY /BUSINESS g. r TRIBAL NATION 3 r VOLUNTEER 3 r COMBINATION 4 r DISASTER RESERVIST 16. Briefly describe your activities /responsibilities as they relate to the course for which you are applying and identify how you will use the information obtained from the course. Attach an organizational chart for the organization being represented and indicate your position. If you need more space, please attach a sheet to this application. See attachment: 0 17. CHECK ONE BOX IN EACH COLUMN THAT BEST DESCRIBES YOUR PRESENT PRIMARY RESPONSIBILITY AND TYPE OF EXPERIENCE AS IT RELATES TO THE COURSE FOR WHICH YOU ARE APPLYING. ALSO ENTER THE NUMBER OF YEARS OF EXPERIENCE. 17a. PRIMARY RESPONSIBILITY 17b. TYPE OF EXPERIENCE 17c. NUMBER OF YEARS OF EXPERIENCE 45 1. r MANAGEMENT 1 . r; INCIDENT COMMAND 2. r TRAINING /EDUCATION 2. r' ADMINISTRATION /STAFF SUPPORT 17d. SIZE OF DEPARTMENT 1 3. r SCIENTIFIC /ENGINEERING 3 . r SUPERVISION 4. r INVESTIGATION 4. r' BUDGET/PLANNING 17e. BUSINESS TYPE 5. r FIRE PREVENTION 5. 1 - PROGRAM DEVELOPMENT /DELIVERY 1. r GOVERNMENT 6. r FIRE SUPPRESSION 6. r COORDINATION/LIAISON 2. r EDUCATION 7. r PROGRAM/ACTIVITY 7. r PUBLIC EDUCATION • 8. r HEALTH 8. r CODE DEVELOPMENT 3 ' C FIRE SERVICE 9. r PUBLIC WORKS 9. r CODE ENFORCEMENT /INSPECTION 4. r LAW ENFORCEMENT 10.E' DISASTER RESPONSE /RECOVERY 10.E SUPPORT SERVICES 5 . r VOLUNTEER AGENCY 11.r' EMERGENCY MEDICAL SERVICE 11.E' RESEARCH AND DEVELOPMENT 6. r' EMERGENCY MANAGEMENT 12.E HAZARD MITIGATION 12.E ARSON 7 • r HEALTH CARE 1 317 EMERGENCY PREPAREDNESS 13.E LAW ENFORCEMENT 8 . E PUBLIC WORKS 14r OTHER (Specify) 14.1 DESIGN AND PLANNING 15.r OTHER(Specify) 18. DATE OF BIRTH 19. GENDER 20a. ETHNICITY July 31, 1956 • I3 Male r Female r HISPANIC or LATINO Ix' NOT HISPANIC or LATINO 20b. RACE (Please check all that apply) 1. r AMERICAN INDIAN or ALASKA NATIVE 2. r ASIAN 3. E BLACK or AFRICAN AMERICAN 4. [x WHITE 5. r NATIVE HAWAIIAN or PACIFIC ISLANDER / FEMA Form 119 -25 -1, AUG 2010 PREVIOUSLY FEMA Form 75 -5 (( -CAD - SECTION III • ENDORSEMENT AND CERTIFICATION 21a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (18 U.S.C. 1001). 21b. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge, or designee, of my organization. All requests for information shall be in writing from said chief or designee. 21c. Further, I understand that the National Emergency Training Center (NETC), the Mt Weather Emergency Operations Center (MWEOC), and the Noble Training Facility (NTF) are not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis. 21d. I agree to abide by the rules, policies and regulations of NETC, MWEOC, and NTF. Failure to do so will result in denial of the student stipend, expulsion from the course, and possible barring from future National Fire Academy (NFA) and Emergency Management Institute (EMI) and FEMA -wide courses. SIGNATURE OF APPLICANT DATE ,(ins, i z l it o 22. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION "By signing this application, I certify that my organization does not discriminate on the basis of age, sex, race, color, religious belief, national origin, economic status, or disability in providing educational opportunities for its employees." 22a. SIGNATURE 22b. PRINTED NAME AND TITLE _ ` JAM_ Keith Montag, County Manager 23. ADDITIONAL ENDORSEME - FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE: 23a. SIGNATURE AND DATE (State Office) 23b. SIGNATURE AND DATE (FEMA Regional Office) 24a. FOR NFA REGIONAL DELIVERY COURSES AND COURSES 24b. FOR EMI AND FEMA -WIDE COURSES DELIVERED AT NETC, MWEOC, DELIVERED AT EMMITSBURG, MD. SUBMIT APPLICATION TO: OR NTF SUBMIT APPLICATION THROUGH THE APPROPRIATE STATE EMERGENCY MANAGEMENT COORDINATOR OR FEMA REGIONAL TRAINING MANAGER TO NETC. NATIONAL EMERGENCY TRAINING CENTER OFFICE OF ADMISSIONS, BLDG. I•216 16825 SOUTH SETON AVENUE 24c. FOR FIELD PROGRAM COURSES, SUBMIT APPLICATION TO EMMITSBURG, MD. 21727 APPROPRIATE SPONSOR. 25. DISPOSITION SIGNATURE OF REVIEWER DATE I- ACCEPTED r REJECTED EQUAL OPPORTUNITY STATEMENT NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, sex, race, color, religious belief, national origin, or disability in their admissions and student - related procedures. Both schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified minority and women candidates are encouraged to apply for all courses. PRIVACY ACT STATEMENT GENERAL • This information is provided pursuant to Public Law 93 -579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.) Section 552a, for individuals applying for admission to NFA, EMI or any FEMA Agency -wide training. AUTHORITY - Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et. seq.; Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, Title 42 U.S.C., Sections 5121 et. seq.; Title 44 U.S.C., Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Act of 1964; and Section 504 of the Rehabilitation Act of 1973. PURPOSES - To determine eligibility for participation in NFA, EMI and any FEMA Agency -wide training courses. Information such as age, sex, and ancestral heritage are used for statistical purposes only. USES - Information may be released to: 1) FEMA staff to analyze application and enrollment patterns for specific courses, and to respond to student inquiries; 2) a physician to provide medical assistance to students who become ill or are injured during courses; 3) Members of the Board of Visitors for the purpose of evaluating programmatic statistics; 4) sponsoring States, local officials, or State agencies to update /evaluate statistics of NFA and EMI and FEMA -wide participants; 5) Members of Congress seeking first party information; and 6) Agency training program contractors and computer centers performing administrative functions. EFFECTS OF NONDISCLOSURE - Personal information is provided on a volunteer basis. Failure to provide information on this form, however, may result in a delay in processing your application and /or certifying completion of the course. INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PL 93.579. SECTION 7(b) - E.O. 9397 authorizes the collection of the SSN. The SSN is necessary because of the large number of individuals who have identical names and birthdates and whose identities can only be distinguished by the SSN. The SSN is used for recordkeeping purposes, i.e., to ensure that your academic record is maintained accurately. Disclosure of the SSN is voluntary. However, if you do not provide your SSN, another number will be substituted, which will delay processing your application or course certificate. PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 9 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless it displays a vaild OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660- 0100). NOTE: Do not send your completed form to this address. E901 IEMC /AII Hazards: Recovery and Mitigation Activities and Responsibilities related to the course include; Coordinate and maintain safety, health, and welfare of the public and environment in the event of an emergency situation or disaster. Preparation of documents required for federal assistance in disaster management activities. Maintain operational readiness of Emergency Operation Center and maintain Emergency Operation Center (EOC) staffing procedures to permit officials to conduct coordinated operations in y emergenciesp se and . I Train staff in all areas of hazard reco nition miti ation emer enc res on g recovery. Develop emergency operations plan, s and provide exercise direction, development and support. Organizational Chart; u, 6 � "s" ° '",, 4, ^'^+>x ` � , `'a` `,' e . f - 9 f,,,„,, Cnun n. . �u :,t of IVA . ,c.o , an ' aa6ettis Sar t h Jon peter Rw ,� ae , 0 , aY o y u n Kare She tfer Te k s is ton } oe H � ' ' - fig ,€ x'm es Ad"' seee9Wees d ; ' „ ', g „„„.4..44444.44°44-4 sea. Mar 5 Vital RayM rry Ate h rE t f`� s p ” ,� i:s.� ..,tax t , � ,. cre- '''.4.; .. ! aWi on ' . }oh,Le is }1f D - S r `` '. Ron Ra c H v Taylo I Scott t u,,�ir K "1 vn v `1. r . J , _ fk f # 9 ['''' (,a Sn AlmonU � r ^( �a �.Sa � _ . : 'tl.eny vs_6x. 4 �� dudt 1 s w, `i , z , ;M - ^r MSG" • fi$B -� 2 's . -., r ^.: Rtd,l Oys R Mercy .. 15 _ ty 3C _. iks p � (i,d went..r "k`„",,. rl'' n c '7* t om r P 644; + ' c t x� �� w e . ,,, t _: „ - °i",-i, , ` t , r s t 4,41.:*.- 1 .0 '3 ,,. e ,,., ?r 2b ., T"3 [.:v- -.`mot 14`1- t,x,' .r A ' g'..) - " L ,' ,. 'SAS °`-. .%04,4,,, .. v .,