Form 9043 Technical Assistance (TA) Request Form for State/Territo

DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications

OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

Technical Assistance (TA) Request Form for State/Territory/Local Agencies

Instructions
Read all instructions before completing this form
Authority: Title XVIII of the Homeland Security Act of 2002, 6 U.S.C. § 101
et seq., and the Implementing Recommendations of the 9/11 Commission
Act or 2007 (6 U.S.C. 579(m) authorizes the collection of this information to
improve emergency communications capabilities in States, territories, local
jurisdictions, and tribal governments.
Purpose: DHS will use this information to collate requests for technical
assistance and evaluate the impact of requests on the attainment of the
National Emergency Communications Plan's goals, objectives, and
initiatives. These request forms will be filled by statewide interoperability
coordinators or their designees at the start of the technical assistance
review cycle, and on an as needed basis when out-of-cycle.

the State/Territory level official whom OEC can contact in
order to clarify the goals and purposes of the requested TA
and to serve as an interface with the State for OEC's delivery
of TA.
Regional Coordinator Contact Information
This pull-down selection identifies the OEC Regional
Coordinator assigned to the State/Territory and provides
his/her contact information for further information about OEC
TA.
Technical Assistance Requests

Routine Uses: This information will be used by and disclosed to DHS
personnel and contractors or other agents who need the information to
assist in activities related to technical assistance services. DHS may share
the information with course development and course curriculum developers
as necessary to improve on the service offerings that are created to
enhance interoperable and operable emergency communications.

This part of the form contains three sub-sections:

Disclosure: Furnishing this information (including your name and e-mail
address) is voluntary; however, failure to furnish the requested information
may delay or prevent the OEC in its ability to determine resources available
to provide technical assistance services to the jurisdiction.

Individual Requests

What is the purpose of this form?
DHS Form 9043, Office of Emergency Communications (OEC)
Technical Assistance (TA) Request Form, is used by States,
Territories, and localities to select TA service offerings from
the annual OEC Technical Assistance Catalog
(www.safecomprogram.gov/SAFECOM/statewideplanning)
and submit them to OEC. These requests include those from
urban areas designated as Urban Areas Security Initiative
(UASI) regions. OEC will consider each request based on the
priority indicated by the State, as well as the anticipated
impact of the service offering on the implementation of the
Statewide Communications Interoperability Plan (SCIP) and
the National Emergency Communications Plan (NECP).
Completed forms should be sent to OEC through the State or
Territory's Statewide Interoperability Coordinator (SWIC).
SWICs serve as focal points for consolidating requests
throughout the State/Territory.
Filling out DHS Form 9043
Requestor Contact Information
This section of the form is typically completed by the SWIC or

1. Individual technical assistance requests, numbers 1 - 4
2. UASI specific technical assistance request, number 5
3. Signatures and submission date

Priority: Requestors should use the columns labeled "Priority"
and "Description of Assistance" to identify up to four areas in
which they want OEC TA, listing them in descending order of
importance, 1 - 4.
Urban/Metro: Number 5 is reserved for a TA request for an
urban area designated as a UASI region in DHS grant guidance.
States with more than one UASI may, if they wish, use
selections 1 - 4 to request TA for other UASI regions in the
State. If your State/Territory has no UASIs, this selection may be
used for a metropolitan urban area in the State.
Description of Assistance: Include in this block a brief
description of the issue or challenge for which TA is needed;
some notional examples might be:
- "Develop a field manual for State's three TICP's"
- "Help State identify eligible frequencies for narrowbanding"
- "Develop a cadre of COMLs for State's rural areas"
TA Offering: Under this column, use the pull down selection to
identify the TA service offering code whose description in the
Catalog matches the nature of the requirement. For example,
codes which would correspond to notional examples above
would be:
- TIC-FOG
- ENG-NB
- TRG-COML

Paperwork Reduction Act Notice. The public reporting burden to complete this information collection is estimated at 25 minutes per response, including time for reviewing
instructions, searching data sources, gathering and maintaining the data needed, and the completing and reviewing the collected information. An agency may not conduct or
sponsor, and a persion 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 informaion, including suggestions for reducing this burden to DHS / National Protection and Programs
Directorate / Office of Cybersecurity and Communications / Office of Emergency Communications, Richard Reed, 202-343-1666, [email protected], ATTN: PRA [1670-NEW]

DHS Form 9043 (3/10)

DEPARTMENT OF HOMELAND SECURITY
OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

Timeframe From/To: Enter a 60 to 90 day timeframe during the
calendar year when OEC could deliver the TA offering. This
information helps OEC align its resources to optimize delivery of
multiple TA offerings across the Nation.
Primary Point of Contact (Name, Phone, Email): Enter the name
and contact information for the specific individual whom OEC
should contact to arrange scheduling, logistics and other
administrative aspects of the TA delivery. This individual may be
different from the SWIC.
SWIC / SCIP POC Signature: The SWIC or the point of contact
for the State's Statewide Communications Interoperability Plan
(SCIP) should sign the form.
State Administrative Agency: The State Administrative Agency
should countersign the form to indicate concurrence with the
individual technical assistance requests from the standpoint of
grants.
Submission Date: Date the form is submitted to OEC by the
State/Territory.

Continuation Sheet
Provide any additional background information or details about
the nature of the requested TA. Also, use this section to
describe any interoperable emergency communications issue or
challenge that does not appear to be covered by the service
offerings in the Catalog.
Completed forms should be sent by fax, scanned into an email,
or sent by mail to:
Fax (202) 343-4015
or
[email protected]
or
245 Murray Lane, SW
Mailstop 0614
Washington, DC 20528-0614
Please e-mail any questions about this form to [email protected]

DHS Form 9043 (3/10)

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Print Form

DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications

OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

Technical Assistance (TA) Request Form for State/Territory/Local Agencies
Upon completion, submit the form to DHS OEC by fax (202-343-4015) or print the
form, scan it, and email it to [email protected]

Requestor Contact Information:
State:

Agency:

Name:

Title:

Phone:

Email Address:

OEC Regional Coordinator Contact Information:
Name / Email:

Select OEC Regional Coordinator

Please indicate each TA Catalog offering requested in order of priority, and describe in detail the assistance needed; how the
technical assistance will meet identified SCIP initiatives or identified gaps; and the desired timeframe for providing the assistance.
The scope of assistance to be delivered will be determined by available OEC TA resources. At least one initiative should provide
direct support to a designated Urban/Metropolitan area. If a State has no UASI area, then select a metropolitan area in the state.

Priority

Description of Assistance

TA Offering

1

Select TA Offering

2

Select TA Offering

3

Select TA Offering

4

Select TA Offering

Urban/
Metro

Description of Assistance

TA Offering

Timeframe
From / To

Primary Point of Contact
(Name, Phone, Email)

Timeframe
From/To

Primary Point of Contact
(Name, Phone, Email)

Select TA Offering

5

SWIC / SCIP POC

State Administrative Agency

Submission Date

DHS Form 9043 (3/10)

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OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

CONTINUATION SHEET - TA REQUEST FORM
Please Provide Additional Background or Details about these Requests (Corresponding to the Respective Request Number).

Priority

Description of Assistance

1

2

3

4

Urban /
Metro

Description of Assistance

5

DHS Form 9043 (3/10)

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