TsunamiReady Supporter Application

TsunamiReady Supporter

Application Form

OMB Control 0648-0419

Expires 5/31/2018

Department of Commerce
National Oceanic & Atmospheric Administration
National Weather Service

TsunamiReady^® Supporter Application

Contact Information
Applicant Entity Name:					Peak # Occupants:
Primary Point of Contact				Secondary Point of Contact
Name:				Name:
Office:				Office:
Title:				Title:
Mailing Address:				Mailing Address:
City:				City:
State, ZIP:				State, ZIP:
Phone:				Phone:
Email Address:				Email Address:
Location of Communications Center (if applicable):
Notes
Please do not write in shaded areas.

Public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other suggestions for reducing this burden to Mike Angove, National Weather Service, 1325 East West Highway, Room 13-110, Silver Spring, MD, 20910.

Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.

TsunamiReady Supporter Criteria* (Check all that apply)
Have Ways to Receive Tsunami Alerts (at least two, one of which includes watches, advisories, and warnings)	☐ NOAA Weather Radio ☐ TV/cable ☐ Radio ☐ Private providers ☐ Wireless Emergency Alerts (warnings only) ☐ Email/text notifications					Other (list below)	Verified ☐
	Hours alerts monitored (at least when entity is occupied):
Have Ways to Communicate Tsunami Alerts (advisories and warnings, at least)	☐ Public address ☐ Sirens ☐ Email/text notifications ☐ Phone ☐ Door-to-door					Other (list below)	Verified ☐
	Hours alerts issued (at least when entity is occupied):
Make Tsunami Hazard or Evacuation Zone Map Available	☐ Posted in central location (at least one per occupied building) ☐ Posted throughout entity ☐ Distributed ☐ Available online (e.g., intranet or website)					Other (list below)	Verified ☐
	Date of most current map:
	Map provider:
Conduct Tsunami Awareness and Preparedness Activities for: ☐ Staff ☐ Residents ☐ Visitors ☐ Others (list):	☐ Annual major outreach/education activity (at least one that includes staff) ☐ Other outreach/education activities Drills and exercises ☐ Tsunami evacuation drill ☐ Participate in community tsunami exercise					Other (list below)	Verified ☐
Have Tsunami Response Plan with Evacuation Instructions	☐ Print copy available ☐ Electronic copy available ☐ Print copy posted in common area					Other (list below)	Verified ☐
Describe additional activities entity does to support TsunamiReady program goals:							Verified ☐

*For more information about these criteria refer to the “TsunamiReady Supporter Information” available at http://www.tsunamiready.noaa.gov/supporters.shtml.

Signature of Applying Official
Name of Applying Entity:
Name of Applying Official:			Title:
Signature:			Date:
NWS Personnel Receiving Application (print name):			Date Received:
NWS Approver Signature
NWS Office:
Print Name:			Title:
Signature:			Date:
NWS Signature in Renewal Year
Name of Renewing Official:			Title:
NWS Office:
NWS Personnel Receiving Renewal Request (print name):			Date Received:
NWS Approver (print name):			Title:
Signature:			Date:

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