Form FEMA Form 089-17 FEMA Form 089-17 RCPT Membership List

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

REGIONAL CATASTROPHIC PLANNING TEAM (RCPT)
MEMBER LIST

OMB 1660-0123
Expiration Date: 12/31/2013

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 0.2 hour per response. The burden estimate includes the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This collection of information is required to obtain or
retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this
form. 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, 1800 South Bell Street, Arlington VA 20598-3005, Paperwork Reduction Project
(1660-0123). NOTE: DO NOT SEND YOUR COMPLETED FORM TO THIS ADDRESS.

PRIVACY ACT STATEMENT
AUTHORITY: Title III of the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act of 2009 (P.L. 110-329) and
Homeland Security Presidential Directive (HSPD)-8.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administration of FEMA
Preparedness Grant Programs, specifically, the Regional Catastrophic Preparedness Grant Program.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of
1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA – 004
Grants Management Information Files System of Records (August 7, 2009, 74 FR 39705) and upon written request, by agreement, or as
required by law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent the organization from receiving grant funding.

ENTER SITE NAME
Requirements for RCPT Membership List
The RCPT Membership List must be updated as appropriate and submitted as part of the Regional Catastrophic Preparedness Grant
Program (RCPGP) Grant Application Package. All jurisdictions that comprise the defined RCPGP site footprint must be directly or indirectly
represented on the RCPT. Direct representation refers to the inclusion of government personnel from the associated jurisdiction, whereas
indirect representation refers to the inclusion of representatives from outside of the jurisdiction that have been granted the authority to
represent the jurisdiction. Indirect representation must be clearly delineated. Additionally, a jurisdictional or subject matter expert
representative may fulfill more than one capacity/ requirement. Each RCPGP site is not limited to the specified group of jurisdictions, and can
incorporate additional jurisdictions, as the Urban Area Working Group (UAWG) and RCPT deem appropriate. A map of each RCPGP site and
a list of included jurisdictions can be found in the applicable RCPGP Guidance and Application Kit.

SME Representation to RCPT
Required RCPT Representation
• Representatives from appropriate State, county, and city agencies and
organizations
• Tribal and regional representatives
• Critical Infrastructure owners and operators
• Representatives from contiguous jurisdictions
• Mutual aid partners

• Local Metropolitan Medical Response System (MMRS) representatives
• Private sector representatives
• Citizen Corps Council representatives
• Local and State Homeland Security and Emergency Management Agency
representatives

Recommended RCPT Representation
• Fire representatives
• Hazmat representatives
• Medical representatives
• Environmental representatives

COMMENTS

FEMA FORM 089-17

• Law enforcement representatives
• Public Health representative
• Other representatives, as appropriate

RCPT Membership List

Name

FEMA FORM 089-17

Agency

Professional Title

Jurisdiction(s)
Represented

Discipline(s)
Represented/
Functional
Expertise

Role on RCPT

E-mail (optional)