Form 1670-00XX SAFECOM Membership Questionnaire

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

SAFECOM Membership Questionnaire
The 2020 SAFECOM Questionnaire is intended to collect public safety experience from each
SAFECOM member for INTERNAL USE ONLY. The information will be loaded into the SAFECOM
Internal Membership Profile Tracker, which is accessible to all SAFECOM members through
SAFECOM HSIN or by request through the SAFECOM mailbox.
PRA Burden Statement: The public reporting burden to complete this information collection is estimated at 15
minutes per response, including the time completing and reviewing the collected information. The collection of
this information is voluntary. 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 of information, including
suggestions for reducing this burden to CISA. Mail Stop 0608, 245 Murray Lane SW, Washington, DC 20598. ATTN:
PRA [OMB Control No. 1670-NEW].
Privacy Act Statement:
Authority: Public Law 109-296, Title VI, §671(b), Title XVIII, §1801(c)(2) authorizes the collection of this information
Purpose: SAFECOM will use this information to collect public safety experience from SAFECOM members in order to
identify membership gaps, obtain updated information on SAFECOM’s membership body, and update SAFECOM
resources regarding the current state of the nation’s emergency communications.
Routine Use: This information requested on this form may be shared externally as a “routine use” to other
SAFECOM members which include emergency response provider organizations at the federal, state, local, and
territory level. A complete list of routine uses can be found in the system of records notice associated with this form,
DHS/ALL-002 Department of Homeland Security (DHS) Mailing and Other Lists System of Records (November 25,
2008, 73 FR 71659). 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-notices-sorns.
Disclosure: Providing this information is voluntary. However, failure to provide this information will prevent the
SAFECOM Internal Membership Profile Tracker from being updated with accurate information available to and
regarding its members in depicting the updated emergency response provider capabilities.
.

Note: This questionnaire has been updated with new content, please complete even if you participated in
the previous 2016 version.

Attachments

Please click box on the left and select picture to upload a professional headshot for
Photo internal use. Note: Photos will not be used on a public facing website.

Click icon box below to attach a copy of your speaker biography.
BIO

If applicable, please type the URL to your LinkedIn:

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

Section 1: SAFECOM Internal Membership
First Name:

Last Name:

Email Address:

Phone Number:

City of Residence:

State of Residence: AK

On average, how many hours a month do you contribute to SAFECOM (i.e. monthly calls,
deliverable development, etc.)?

☐ < 1 Hours
☐ 1-4 Hours
☐ 5-9 Hours
☐ 10+ Hours

Section 2: Association Representative Information

SAFECOM consists of association representatives and at-large members. The following section
pertains to associations represented in SAFECOM. If you are an at-large member, please skip to
Section Three.
Please provide the name of the association you represent on SAFECOM:
Please select the range that describes the size of your Association’s membership:

☐ < 100
☐ 100 to 1,000
☐ 1,001 to 10,000
☐ 10,001 to 50,000
☐ 50,001 to 100,000
☐ >100,001

Please provide your association’s point of contact (if difference from the SAFECOM
representative):
Please provide your association POC’s email:
Please provide your association POC’s phone number:
Is there a link to SAFECOM on your Association’s website?
☐ Yes
☐ No

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

Please provide any additional memberships you have with other public safety/emergency
communications associations.

Section 3: Public Safety Service

Please provide the status of your first responder career. Note: please select multiple boxes if
applicable (i.e., you have "Retired" from an organization and are now "Active" with a
separate organization):
☐ Active
☐ Retired
☐ Other (please specify):
Please provide your years of service:
Please select the public safety disciplines relevant throughout your career:
☐ Agriculture (Fish and Wildlife Services, Forestry)
☐ Emergency Communications (911 Tele-communicator)
☐ Emergency Management
☐ Fire Service
☐ Law Enforcement
☐ Emergency Medical Services/Medical/Health
☐ Public Works (Water/Sewer, Gas, Electricity, etc.)
☐ Transportation
☐ Other (please specify):
Please provide the following information:
Current Department or Agency:
Work Address:
Work Email:
Work Phone Number:
Please provide a short description of your role:

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

Please provide the level of government you currently serve:
☐ Local ☐ State ☐ Federal ☐ Tribal ☐ Territorial
Years of your tenure:
☐ < 1 year
☐ 1-10 years
☐ 11-20 years
☐ 21-30 years
☐ 31-40 years
☐ 41+ year
Which public safety disciplines are relevant to your current employment?
☐ Agriculture (Fish and Wildlife Services, Forestry)
☐ Emergency Communications (911 Tele-communicator)
☐ Emergency Management
☐ Fire Service
☐ Law Enforcement
☐ Emergency Medical Services/Medical/Health
☐ Public Works (Water/Sewer, Gas, Electricity, etc.)
☐ Transportation
☐ Other (please specify):
Please select the population range that best describes the population of your current
organization’s jurisdiction serviced:
☐ ≤ 100,000
☐ 100,001-500,000
☐ 501,000-1,000,000
☐ > 1,000,000
Please indicate the number of responses your current organization responds to each year:
☐ ≤50
☐ 50-100
☐ 101-200
☐ 201-500
☐ 501-1,000
☐ >1,001
Does your current position entail work with tribal nations?
☐ Yes
☐ No

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

If yes, please select the range of years:
☐ < 1 year
☐ 1-10 years
☐ 11-20 years
☐ 21-30 years
☐ 31-40 years
☐ 41+ years
Please list membership to any other national associations, public safety organizations, or
special interest groups you are an active member of:

Please provide a brief description of any accolades or recognition of service received:

Please provide the level(s) of government you served in past employment:
☐ Local
☐ State
☐ Federal
☐ Tribal
☐ Territorial
Please indicate which public safety disciplines were relevant to your past position(s).
☐ Agriculture (Fish and Wildlife Services, Forestry)
☐ Emergency Communications (911 Tele-communicator)
☐ Emergency Management
☐ Fire Service
☐ Law Enforcement
☐ Emergency Medical Services/Medical/Health
☐ Public Works (Water/Sewage, Gas, Electricity, etc.)
☐ Transportation
☐ Other (please specify):
Do you have any experience working with tribal nations?
☐ Yes
☐ No

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

Section 4: Volunteer Experience

Please provide the organization(s) you volunteer(ed) at:

Please provide your volunteer role(s):

Please provide a short description of your volunteer role(s):

Please indicate the number of years for each organization(s) you volunteer(ed) at:

Section 5: Public Safety Experience

Please select the type of events you have experience with:
☐ Planned Events
☐ Unplanned Events
☐ Natural Disasters
☐ Multi-Jurisdictional
Please list any major events to which you provided response assistance (e.g., natural
disasters, major sporting events, parades/ rallies/ inaugurations, etc.):

Please select the following technological capabilities you have experience with:
☐ Long-Term Evolution (LTE)
☐ Cybersecurity
☐ Information Technology (IT)
☐ Geographic Information Systems (GIS)
☐ Emerging Technologies (please specify):
☐ Other(s) (please specify):
Please provide your areas of expertise and usage.

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

Section 6: Education

Please select your highest level of education (optional):
☐ High School Diploma
☐ Associate’s Degree
☐ Bachelor’s Degree
☐ Master’s Degree
☐ Doctoral Degree

Please note other languages in which you are proficient:
Please select the following technological capabilities you have experience with:
☐ Land Mobile Radio (LMR)
☐ Auxiliary Communications (AuxComm)
☐ Communications Unit Leader (COML)
☐ Communications Unit Technician (COMT)
☐ Incident Communications Center Manager (INCM)
☐ Information Technology Service Unit Leader (ITSL)
☐ Incident Tactical Dispatcher (INTD)
☐ Radio Operator (RADO)
☐ Exercise Evaluator/Master Exercise Practitioner (MEP)
☐ Other(s) (please specify):
Please select the following documents you have either used or developed:
☐ Memorandum of Understanding (MOU)
☐ Standard Operating Procedure (SOP)
☐ Continuity of Operations Plan (COOP)

Section 7: External Conference Attendance

Please provide any public safety conference(s) you attended this year and any public safety
conference(s) you plan to attend in the near future.

Please provide any external public safety conference(s) you attended on behalf of
SAFECOM this year and any public safety conference(s) you plan to attend in the near
future.

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM

OMB Control Number: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

Would you be interested in staffing a SAFECOM information booth, being a SAFECOM
panelist, or presenting the SAFECOM Introduction Presentation at external public safety
conferences?
☐ Yes
☐ No

Section 8: Other

Please provide the Cyber Security and Infrastructure Security (CISA) services you have
utilized through your association or organization (Technical Assistance, Priority
Telecommunications GETS, WPS, TSP, SCIPS, etc.):

Please select the social media platforms you use:
☐ LinkedIn
☐ Facebook
☐ Twitter
☐ Other(s) (please specify):
Please provide any additional information or comments which you feel might assist this
effort:

Submit

DISCLAIMER: Any information collected is for internal use only, not to be distributed outside of SAFECOM