Form FEMA Form 119-17-1 FEMA Form 119-17-1 Request For Housing Accommodations

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control Number: 1660-0029
Expiration: 5/31/2017

REQUEST FOR HOUSING ACCOMMODATIONS
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 6 minutes per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, and submitting this form.
This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless it
displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this
burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street
SW, Washington, DC 20472, Paperwork Reduction Project (1660-0029). NOTE: Do not send your completed survey to the above
address.

PRIVACY ACT STATEMENT

Authority: Public Law 93-498, 15 U.S.C §. 2206, E.O. 12127 and E.O. 12148.

Purpose: This information is being collected for the primary purpose of assigning housing and/or training space at the National Emergency
Training Center.
Routine Uses: 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 - 011 Training and
Exercise Programs System of Records System of Records Notice and upon written request, by agreement, or as required by law. The
Department's full list of system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-noticessorns
Disclosure: The disclosure of information on this form is voluntary; however, failure to provide the information requested may result in the
inability to assign/obtain housing and/or training space. Information such as gender is necessary because the accommodations are of dormitory
type and it is required to separate individuals by gender. Information will only be released as permitted by law.
STATUS
FEMA Employee*

Contract Instructor

Contractor

Other Specify

DRAFT

* Must present a copy of travel authorization or invitational travel, if applicable, at the time of registration.
DATE OF DEPARTURE NAME OF INDIVIDUAL REQUESTING HOUSING

DATE OF ARRIVAL
PURPOSE OF VISIT

IT IS REQUESTED THAT THE FOLLOWING INDIVIDUAL(S) BE PROVIDED HOUSING AT NETC
NAME OF INDIVIDUAL

PURCHASE
ORDER NUMBER
(if any)

GENDER
(M/F)

DISABILITY OR ACCESS
AND FUNCTIONAL NEEDS
(Y/N)

ACCESSIBILITY ACCOMMODATIONS REQUIRED

Requestor certifies that the housing requested above is in accordance with NETC SOP
No. 119-3, Facility Utilization and Expenses at the National Emergency Training Center.
APPROVED
YES
NO
BILLING INFORMATION
USE ONLY

SIGNATURE (Individual Requesting Housing)

SIGNATURE (NETC Program Office Head or Official Designee) SIGNATURE (Director, NETC Management and
Operations Designee)

FEMA FORM 000-0-0 (05/15)

Exempt for Payment
House included in cost

House not included in cost
Must pay prevailing rate
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