Form DHS Form 9043 DHS Form 9043 Technical Assistance (TA) and Statewide Communication In

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1670-0023

Expiration Date: 06/30/2019
EMERGENCY COMMUNICATIONS DIVISION/INTEROPERABLE
COMMUNICATIONS TECHNICAL ASSISTANCE PROGRAM (ECD/ICTAP)
TECHNICAL ASSISTANCE (TA) AND
STATEWIDE COMMUNICATION INTEROPERABILITY PLAN (SCIP) WORKSHOP

Instructions

Read all instructions before completing this form.
Privacy Act Statement
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.
Purpose: The primary purpose of this collection is 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.
Routine Uses: The information collected may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended.
This includes using the information as necessary and authorized by the routine uses published in DHS/All-002 Mailing and Other Lists Records System
of Records (November 28, 2008, 73 FR 71659).
Disclosure: Providing this information is voluntary, however, failure to provide this information may delay or prevent the Emergency Communications
Division in determining resources available to provide technical assistance services to the jurisdiction.
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 person 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
information, including suggestions for reducing this burden to DHS/CISA/ECD, 245 Murray Lane, SW, Mail Stop 0640, Arlington, VA 20528 ATTN: PRA
[1670-0023].

What is the purpose of filling out this Form?
DHS Form 9043,Emergency Communications Division (ECD) Technical Assistance (TA) and Enhanced Statewide Communication Interoperability Plan
(SCIP) Workshop Request Form, is used by States and Territories, to request Enhanced SCIP Workshops and TA service offerings from the ECD
Technical Assistance Guide.
Requests for Enhanced SCIP Workshops and Technical Assistance Service Offerings should complement each other and maybe submitted together or
separately. ECD will consider requests based on the priority indicated by the State as well as the anticipated impact of the service offering on the
implementation of the National Emergency Communications Plan (NECP) and the respective SCIP.
Forms should be completed by the State/Territory's Statewide Interoperability Coordinator (SWIC) or SCIP point of contact and sent to ECD using the
fillable, on-line form posted on the SAFECOM web site at: https://www.dhs.gov/ictapscip-resources. Scanned versions as attachments may be emailed
to: [email protected].

Filling out DHS Form 9043
Requester Contact Information
This section of the form is typically completed by the SWIC, SCIP POC or the State/Territory level official whom ECD can contact to clarify the goals and
purposes of the requested Workshop and/or TA service offering and who will serve as the point of contact with ECD.
ECD Coordinator Contact Information
This pull-down selection provides contact information for the ECD Coordinator assigned to the State/Territory, who can be contacted for further
information about requesting ECD TA and SCIP Workshops.
Enhanced SCIP Workshop Requests
For FY2018, ECD/ICTAP is accepting requests for Enhanced SCIP workshops. The Enhanced SCIP is a series of workshops spread over several
months that target State/Territory interoperability focus areas:
• Governance
• Technology
• Funding Sustainability
• Strategic Goals & Implementation Planning
• Evaluation/Progress Management

DHS Form 9043 (9/18)

Page 1 of 4

Priority Technical Assistance (TA) Service Offering Requests
FY2018, ECD/ICTAP is offering these new Priority TA Service Offerings:
*Priority TA Requests do not count against the State/Territory's initial allotment.
• COMU Policy and Planning Development
• COMU Assistance under Emergency Management Assistance Compact (EMAC)
• Next Generation 9-1-1
• Alerts and Warnings

TA Guide Service Offering Selections
Priority: Requesters may select up to five additional TA service offerings and list them in order of importance using the column labeled "Priority".
OEC TA Offerings Pick List: Under this column, use the pull down to select the appropriate TA service offering in the priority order desired.
Timeframe From/To: Enter a 30 to 90 day in which ECD could deliver the TA offering. This information helps ECD align its resources to optimize delivery
of multiple TA offerings across the Nation.
Primary Point of Contact (Name, Phone, and Email): Enter the name and contact information for the individual whom ECD should contact to arrange
scheduling, logistics and other administrative aspects of the TA delivery. This individual may be different from the SWIC.
Description of Assistance: Provide additional background or details about each request and a brief description of the desired outcome/deliverable for the
request in the corresponding number block on continuation sheet* (page 5 of this form).
To illustrate some notional examples might be:
• "Develop/maintain an effective governance structure”
• "Establish formal written instructions for operational and technical procedures of the XYZ radio system”
• “Maintain accurate and up to date communications plans for all hazards situations”
• ”Establish effective and consistent policies and procedures for developing and managing COMU resources”
Requester Endorsements:
• Signature (SWIC/SCIP POC)
• Request Submission (Date)
• SIEC/SIGB/Chair Date of Concurrence/Notification
o Notification may be given verbally or by email
Submission Date: Date the form is submitted to ECD by the State/ Territory SWIC/SCIP POC.
Continuation Sheet*
Provide any additional background information or details about the requested TA. Also, use this section to describe interoperable emergency
communications issues or challenges that do not appear to be covered by the service offerings in the Guide, and that are identified in the SCIP.
An interactive version of this form may be accessed on the SAFECOM website at: https://www.dhs.gov/ictapscip-resources. The completed form will be
automatically sent to ECD with a copy to the Requester and the ECD Regional Coordinator.
Scanned versions as attachments and/or any questions about this form may also be emailed to: [email protected].

DHS Form 9043 (9/18)

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DEPARTMENT OF HOMELAND SECURITY

OMB No. 1670-0023

Expiration Date: 06/30/2019
EMERGENCY COMMUNICATIONS DIVISION/INTEROPERABLE
COMMUNICATIONS TECHNICAL ASSISTANCE PROGRAM (ECD/ICTAP)
TECHNICAL ASSISTANCE (TA) AND
STATEWIDE COMMUNICATION INTEROPERABILITY PLAN (SCIP) WORKSHOP
TA Service Offerings and Enhanced SCIP Workshop requests can be submitted by accessing the online form located on the SAFECOM website: https://
www.dhs.gov/ictapscip-resources or by scanning this completed form and emailing it to: [email protected]

(Requester) Contact Information:
State:
Name:
Phone:
Email:
ECD Regional Coordinator:

Select ECD Coordinator

Enhanced SCIP Workshop:

Requester's target date range for Workshop:

The Enhanced SCIP is a series of workshops spread out over
several months that target State/Territory interoperability focus areas.
Priority TA Requests

From:

Priority TA Service Offerings:

OEC/ICTAP is offering these new Priority
TA Service Offerings:

COMU Policy and Planning Development

*Priority TA Requests do not count against
the State/Territory’s initial allotment
(Selected below).

Next Generation 9-1-1

Priority

To:

COMU Assistance under Emergency Management Assistance Compact (EMAC)

Alerts and Warnings

ECD TA Offerings Pick List

Timeframe
From/To

Primary Point of Contact
(Name, Phone, Email)

1

2

3

4

5

SWIC/SCIP POC

SIEC/SIGB/Chair Date of Concurrence

Notification may be given verbally or by email

Submission Date

DHS Form 9043 (9/18)

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

Customized TA Requirements/Description of Assistance

1

2

3

4

5

Submit by Email

DHS Form 9043 (9/18)

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