Form DHS Form 9043 DHS Form 9043 CISA Technical Assistance (TA)Request Form

DEPARTMENT OF HOMELAND SECURITY

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

CYBERSECURITY AND INFRASTRUCTURE SECURITY AGENCY (CISA)

TECHNICAL ASSISTANCE (TA) REQUEST FORM

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 s eq., and the Implementing Recommendations of the 9/11
Commision 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
requestson the attainment of the National Emergency
Communications Plan’s goals, objectives, and initiatives.
Routine Uses: The information collected m ay be disclosed
as generally permitted under 5 U.S.C. § 552a(b) of the Privacy
Act of 1974, as am ended. 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
CISA in determining resources available to provide technical
assistance services to the jurisdiction.

What is the purpose of filling out this Form?
DHS Form 9043, Cybersecurity and Infrastructure Security
Agency (CISA) Technical Assistance (TA) and Statewide
Communication Interoperability Plan (SCIP) Workshop
Request Form, is used by States and Territories, to request
SCIP Workshops and TA service offerings from the CISA TA/
SCIP Guide. State/Territories can submit their TA/SCIP
requests by:
•
•
•
•

Completing the fillable request form on the SAFECOM
website at:
https://www.cisa.gov/publication/ictapscip-resources
Clicking on the Submit Button bottom of the last page
Or
Saving the completed form as a PDF using the following
file format:
“State Name_FY2020_TA_Request_MM_DD_YYYY”
Emailing the completed PDF 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 CISA 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 CISA.
CISA Emergency Communications Coordinator
This pull-down selection provides contact information for the
CISA Coordinator assigned to the State/Territory, who can be
contacted for further information about requesting CISA TA and
SCIP workshops.
SCIP Workshop Requests
For FY2020, CISA/ICTAP is accepting requests for SCIP
Workshops. SCIP is a series of scoping and planning calls and inperson workshop meeting(s) spread over several months that
target State/Territory interoperability focus areas:
•
•
•
•
•

Governance
Technology
Funding Sustainability
Strategic Goals & Implementation Planning
Evaluation/Progress Management

Technical Assistance (TA) Service Offering Requests:
FY2020, CISA/ICTAP is offering these new and updated
TA Service Offerings:
•
•
•
•
•
•
•
•
•
•

Statewide Communication Interoperability Plan Workshop
Electronic Tactical Interoperable Communications Field
Operations Guide Development
Leveraging Broadband Technologies and Data
Operability/Interoperability in Support of Public Safety
Next Generation 9-1-1/Strategic Planning Support
9-1-1/PSAP Cyber Awareness
LMR/LTE Communications Systems Engineering Support
Encryption Planning and Usage
Information Technology Service Unit Leader
Auxiliary Communications Train-the-Trainer
Grant Funding for Emergency Communications

Paperwork Reduction Act Notice. The public reporting burden to complete this inform ation collection is estimated at 25 minutes per response, including time f or
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/Cybersecurity and
Infrastructure Security Agency (CISA) Richard Tenney (703) 705-6281, [email protected] ATTN: PRA [1670-0023].

DHS Form 9043 (7/23)

Page 1

DEPARTMENT OF HOMELAND SECURITY

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

CYBERSECURITY AND INFRASTRUCTURE SECURITY AGENCY (CISA)

TECHNICAL ASSISTANCE (TA) REQUEST FORM

CISA TA Offerings Pick List: Under this column, use the pull
down to select the appropriate TA service offering in the priority
order desired.
Time frame From/To: Enter a 30 to 90 day in which CISA could
deliver the TA offering. This information helps CISA 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 CISA
should contact to arrange scheduling, logistics and other
administrative aspects of the TA delivery. This individual m ay
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).

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 CISA 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.
General TA questions can be emailed to:
[email protected].

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”

DHS Form 9043 (7/23)

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DEPARTMENT OF HOMELAND SECURITY

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

CYBERSECURITY AND INFRASTRUCTURE SECURITY AGENCY (CISA)

TECHNICAL ASSISTANCE (TA) REQUEST FORM

TA Service Offerings and SCIP Workshop requests can be submitted
by completing the fillable form located on the SAFECOM website:
https://www.cisa.gov/publication/ictapscip-resources
Email the completed PDF to: [email protected]

(Requestor) Contact Information:

State:
Name:
Phone:
Email:

Sector Coordinators: Select Sector Coordinator

SCIP Workshop:

Requester’s target date range for Workshop:

To request a SCIP workshop:
•

Check the box above and insert the desired target date(s)
for the workshop in the space provided

DHS Form 9043 (7/23)

From:

To:

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

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

TECHNICAL ASSISTANCE (TA) REQUEST FORM

CISA/ICTAP is offering these new and improved TA Service Offerings






SCIP Workshop
Electronic Field Operations Guide (eFOG)
Broadband Technologies/Interoperability
Next Generation 9-1-1/Strategic Planning Support
9-1-1/PSAP Cyber Awareness







LMR/LTE, Systems Engineering
Information Technology Service Unit Leader
AUXCOMM Train-the-Trainer
Encryption Planning and Usage
Grant Funding for Emergency Communications

Note: If the Requested TA is Strategic, please check the box in the "Priority" column and describe what Goal or Objective it aligns with (i.e., SCIP, NGA, NECP or State Markers)
in the corresponding block on the Continuation Sheet (Page 5) of this form.

TA Guide Service Offerings Selections
Priority

CISA TA Offerings Pick List

1

Select CISA TA Offering

2

Select CISA TA Offering

3

Timeframe
From/To

Primary Point of Contact
(Name, Phone, Email)

Select CISA TA Offering

4

Select CISA TA Offering

5

Select CISA TA Offering

SWIC/SCIP POC

SIEC/SIGB/Chair Date of Concurrence
Notification may be given verbally or by email

Submission Date

DHS Form 9043 (7/23)

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DEPARTMENT OF HOMELAND SECURITY

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

CYBERSECURITY AND INFRASTRUCTURE SECURITY AGENCY (CISA)

TECHNICAL ASSISTANCE (TA) REQUEST FORM

CONTINUATION SHEET – TA REQUEST

Priority

TA Requirements/Description of Assistance

1

2

3

4

5

SUBMIT BY EMAIL

DHS Form 9043 (7/23)

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