Form DS-5506 Local American Citizen Skills/Resources Survey

U. S. Department of State

EMBASSIES/CONSULATES OF THE UNITED STATES OF AMERICA

OMB NO. 1405-XXXX
EXPIRES
Estimated Burden - 15 minutes

LOCAL AMERICAN CITIZEN SKILLS/RESOURCES SURVEY
U.S. citizens abroad may possess critical skills and resources invaluable for helping other Americans in a time of
crisis. The Consular Section of the U.S. Embassy/Consulate would appreciate your assistance in identifying these
skills and resources. Please provide relevant details about yourself and return this survey to us by e-mail, fax, or in
person to the American Citizens Services unit of the Consular section of the nearest U.S. Embassy/Consulate.
Family members may submit separate forms or you may include their information on this form with their consent.
We will keep your responses confidential. Please see the Privacy Act Statement on page 3.
Full Name (Last, First, MI)

Date (mm-dd-yyyy) Telephone Number(s)

Address

Email Address

City

Country

OCCUPATION(S) AND OTHER SKILLS
Please place an 'X' in each box that describes the skills you possess.
Medical

Engineering Operation

Emergency Response

Heavy Machinery

Search and Rescue

Construction/Extraction

Social Services

Electrical

Foreign Language (Oral / Written)

Carpentry

Military

Other (If other, Please Specify)

Law Enforcement
Food Service

Please provide additional details about the skills marked above.

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LANGUAGE SKILL
1. In the first box, please indicate your level of proficiency as a "Translator." In the second box, please indicate
your level of proficiency as an "Interpreter."
Level 1 - Communication is limited to a few words.
Level 2 - Comprehension of very simple written material.
Level 3 - Can satisfy social demands and limited work requirements.
Level 4 - Functioning in a social and professional setting.
Level 5 - Equivalent to a native speaker.
Translator (T) - convert one language into another through writing.
Interpreter (I) - convert one language into another through oral communication.
T

I
Arabic

Hindi

Swahili

Armenian

Indonesian

Tagalog

Bengali

Indonesian/Malay

Telugu

Chinese, Mandarin

Italian

Thai

Creole

Japanese

Turkish

English

Korean

Urdu

Farsi/Dari

Persian

Vietnamese

French

Portuguese

Zulu

German

Russian

Hebrew

Spanish
Other Languages

YES

NO

(If yes, specify)

RESOURCES
In the event of a crisis, I may be able to provide:
TRANSPORTATION

TYPE

SHELTER
TYPE
FOOD SERVICE LOCATION

PASSENGER CAPACITY
LOCATION

CAPACITY
CAPACITY

Additional Resources or Information

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RESIDENCY STATUS
Please place an 'X' in each box that applies.

I am permanently a resident in

.
Country

I travel to and from

several times a year.
Country

I am temporarily a resident in

until
Country

.
Date (mm-dd-yyyy)

Signature, or Typed Name if Submitted by Email

Date (mm-dd-yyyy)

PRIVACY ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §
4802(b), 31 U.S.C. § 1342, 22 CFR § 71.1 and 22 CFR § 71.6. Responding to this survey is
purely voluntary.
PURPOSE: The principal purpose of gathering this information is to identify U.S. citizens
residing in the country who may possess critical skills and resources invaluable for helping
other Americans in a time of crisis.
Absent your prior written consent, no information on this form may be disclosed to any
persons or agency unless such a disclosure would be permitted by the Privacy Act, 5 USC
552a (b) ("Conditions of disclosure").
ROUTINE USES: The information on this form may include communications to and from
U.S. embassies, U.S. consulates, and consular agencies; federal, state, and local
government agencies; members of Congress; officials of foreign governments; U.S. and
foreign courts; U.S. and foreign nongovernmental organizations, including disaster or
emergency relief organizations such as the International Red Cross, Red Crescent and
others.

PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 15 minutes
per response, including time required for searching existing data sources, gathering the
necessary documentation, providing the information and/or documents required, and
reviewing the final collection. You do not have to supply this information unless this
collection displays a currently valid OMB control number. If you have comments on the
accuracy of this burden estimate and/or recommendations for reducing it, please send them
to: A/GIS/DIR, Room 2400, SA-22, U.S. Department of State, Washington, DC 20522-2202.

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