Form DHS Form 9042 DHS Form 9042 CISA Technical Assistance (TA) Evaluation Form

OMB No. 1670-0023
Expiration Date: 07/31/2023

DEPARTMENT OF HOMELAND SECURITY
CYBERSECURITY AND INFRASTRUCTURE SECURITY AGENCY (CISA)

TECHNICAL ASSISTANCE (TA) EVALUATION FORM

Instructions
Read all instructions before completing this form

Privacy Act Statement

Filling out DHS Form 9042

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.

Technical Assistance Engagement Evaluator:

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.

SECTION 1

Routine Uses: The information collected maybe 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).

Work Order Number: Enter Work Order Number (e.g., WO18-056)

Disclosure: Providing this information is voluntary, however, failure
to provide this information may delay or prevent the Cybersecurity
and Infrastructure Security Agency (CISA) in determining resources
available to provide technical assistance services.

Each participant in a CISA TA workshop or the principal stakeholder
involved with a TA engagement is requested to complete this form.

Title: Enter the name of the Technical Assistance service provided,
(e.g., Standard Operating Procedures, Communications Unit Planning,
Auxiliary Communications Workshop, etc.)
SWIC/TA Point of Contact: Enter the name of the person completing
this form, (Primary/on-site contact for the TA service)
Location: Enter the workshop, seminar, course location, (where was the
TA service provided)
Date: Enter the date of the workshop, seminar, course (date TA service
was provided)
Instructor(s): Enter the name of the CISA Staff/SME that provided
the TA service

SECTION 2

What is the purpose of this form?
DHS Form 9042, Cybersecurity and Infrastructure Security Agency
(CISA) Technical Assistance (TA) Evaluation Form, is voluntarily
completed by stakeholders receiving CISA TA.

Evaluate the Technical Assistance service provided: Please answer the
following 7 questions by checking the appropriate box using the below
evaluation scale:

CISA will use the information collected through these evaluations to
assess the effectiveness of its TA service offerings and for continued
improvement to its TA planning.

1 - Strongly Disagree
2 - Somewhat Disagree
3 - Neutral
4 - Somewhat Agree
5 - Strongly Agree

TA service offerings are described in the CISA TA Guide.
(https://www.cisa.gov/publication/ictapscip-resources)

SECTION 3
Please answer the following 5 questions to improve the quality of future
Technical Assistance Service Offerings.
Submitting the completed form:
TA Evaluations may be completed and submitted electronically at
https://www.cisa.gov/publication/ictapscip-resources or PDF copies may
be submitted via email to: [email protected].

Paperwork Reduction Act Notice.
The public reporting burden to complete this information collection is estimated at 5 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. 245 Murray Lane, SW, Mail Stop 0640, Arlington, VA 20528 ATTN:
PRA [1670-0023]

DHS Form 9042 (7/23)

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Title:

Work Order Number:

SWIC/TA Point of Contact:

Location:

Date(s):

Instructor(s):

Please answer the following questions about your experience in this Technical Assistance Workshop according to the scale below:
1

2

3

4

5

Strongly Disagree

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

N/A

1

2

3

4

5

1. This Technical Assistance service was successful in assisting us with our Objectives
and Goals.
2. The workshop material was presented in a professional manner and was clear and
easily understood by the participants.
3. The Technical Assistance final deliverable(s) met or exceeded expectations.
4. This Technical Assistance was received on time, as scheduled during the planning
process with CISA.
5. The instructor’s presentation, content knowledge and class exercises were effective
in enhancing course content.
6. This Technical Assistance improved our interoperable emergency communications
knowledge and capabilities.
7. I would recommend this Technical Assistance Service Offering.
Please use the following sections to provide any additional information to improve the quality of future Technical Assistance Service
Offerings:
1. What did you like most about this Technical Assistance?

2. What did you not like, or what seemed to not work well?

DHS Form 9042 (7/23)

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3. What suggestions do you have for improving the learning experience?

4. What would you add or delete from this Technical Assistance Workshop?

5. How does this Technical Assistance support and/or enhance interoperable emergency communications in your State/region/
locality?

For More Information about CISA/ICTAP Technical Assistance (TA) Offerings and Resources
Visit: https://www.cisa.gov/safecom/ictapscip-resources
Please E-Mail this completed form to: [email protected]
Or complete it on-line at: https://www.cisa.gov/publication/ictapscip-resources

SUBMIT BY EMAIL

DHS Form 9042 (7/23)

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