Form 9042 Office of Emergency communications Technical Assistance

DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications
Technical Assistance (TA) Evaluation Form

OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

Instructions
Read all instructions before completing this form
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 to
improve emergency communications capabilities in States, territories, local
jurisdictions, and tribal governments.
Purpose: DHS will use this information to conduct a review of the
effectiveness and adequacy of technical assistance services provided to
State and local officials for interoperable and operable communications.
These evaluation forms will be filled in at the completion of technical
assistance services to participants of those events.
Routine Uses: This information will be used by and disclosed to DHS
personnel and contractors or other agents who need the information to
assist in activities related to technical assistance services. DHS may share
the information with course development and course curriculum developers
as necessary to improve on the service offerings that are created to
enhance interoperable and operable emergency communications.
Disclosure: Furnishing this information (including your name and e-mail
address) is voluntary; however, failure to furnish the requested information
may delay or prevent completion of the review of adequacy and
effectiveness of technical services provided by the OEC.

What is the purpose of this form?
DHS Form 9042, Office of Emergency Communications Technical
Assistance (TA) Evaluation Form, is voluntarily completed by
stakeholders receiving OEC TA.
OEC 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.
Note: the term “deliverable” for purposes of this form refers to a work
shop, engagement or work product that OEC/ICTAP delivers or provides
to participants and stakeholder(s) as part of a TA service offering. For
example, a COML training work shop, SOP development engagement or
CASM support would all qualify as a “deliverable” for purposes of this
evaluation form. TA service offerings are described in the OEC TA
Catalog. (www.safecomprogram.gov/SAFECOM/statewideplanning)

Filling out DHS Form 9042

Deliverable:
Enter the name of the TA work shop or service offering in which you
participated, for example, "SOP-DEV" or "development of SOP for
dispatch center."

Technical Assistance Deliverable Evaluator:
Each participant in an OEC TA work shop or the principal stakeholder
involved with a TA engagement is requested to complete two sections of
this form.
In this section, enter your name, title, agency (even if it is the same as
hosting/requesting agency); phone number; fax number; and email
address. OEC will use this information for follow up about your
comments and recommendations.

Review Work Plan for the Requested TA, Evaluate the TA
Deliverable Using the Checklist Provided:
Section 1, Was the Deliverable Received on Schedule:
Please answer this question and then rate the six criteria using the
following scale:
E - exceeded expectations
S - satisfactory
U - unsatisfactory
NA - not applicable
- Technical accuracy and soundness
- Completeness
- Deliverable content structure and organization
- Scope and requirements associated with TA request
- Timely delivery (SWIC/POC only)
- Flexibility (in reacting to any changing needs/requirements by the
POC agency) (SWIC/POC only)

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 persion 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 informaion, including suggestions for reducing this burden to DHS / National Protection and Programs
Directorate / Office of Cybersecurity and Communications / Office of Emergency Communications, Richard Reed, 202-343-1666, richard.reed@hq.dhs.gov, ATTN: PRA [1670-NEW]

DHS Form 9042 (3/10)

DEPARTMENT OF HOMELAND SECURITY

OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

If you mark any criterion as U (unsatisfactory), please provide a comment
about that rating.

Section 2, Overall Was the Recipient Satisfied with the
Quality and Timeliness of the Deliverable?
Please answer yes or no. If no, please describe why not.

Please Include Any Additional Relevent Information:
Use this section to discuss any recommendations you have about the
specific deliverable.

(SWIC / POC only) Please Include Any Suggestions on How
OEC Might Improve This Type of Technical Assistance for
Future Deliveries:
This section is reserved for SWIC or POC use. Enter any
recommendations or ideas you have for other technical assistance that
would support interoperable emergency communications in your area
of responsibility.
Submitting the completed form:
For purposes of this form, the term "POC" refers to the Statewide
Interoperability Coordinator (SWIC) or other authorized representative
of the State/Territory who requested or hosted the TA engagement.
The POC should enter his/her name and provide a copy to the State
Administrative Agency (SAA) for that office's information.
Turn in completed forms to the SWIC / POC.
The SWIC/POC will add his/her comments and forward completed
forms by fax, scanned into an email, or sent by mail to:
Fax (202) 343-4015
or
OEC@dhs.gov
or
245 Murray Lane, SW
Mailstop 0614
Washington, DC 20528-0614
Please e-mail any questions about this form to OEC@dhs.gov

(For OEC Use only) Technical Assistance Work Order
OEC will compete this entry.

DHS Form 9042 (3/10)

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Print Form
DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications
Technical Assistance (TA) Evaluation Form

OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

Upon Completion E-Mail form to oec@dhs.gov
Deliverable:
Technical Assistance Deliverable Evaluator:
Name:
Phone:

Title:
Fax:

Agency:
Email Address:

Please evaluate the TA Deliverable using the criteria provided below.
1.

Was the deliverable received on schedule?
If no, what was the reason for late delivery?

Please rate the deliverable product (as "exceeded expectations" [E], "satisfactory" [S], "unsatisfactory" [U], or
"not applicable" [N/A] for each of the following criteria. Please elaborate as needed on any rating.
• Technical accuracy and soundness:
Selected Rating

• Completeness:
Selected Rating

• Deliverable content structure and organization:
Selected Rating

• Scope and requirements associated with TA request:
Selected Rating

• Timely delivery (SWIC / POC only):
Selected Rating

• Flexibility (in reacting to any changing needs/requirements by the State) (SWIC / POC only):
Selected Rating

DHS Form 9042 (3/10)

Page 3

Office of Emergency Communications
Technical Assistance (TA) Evaluation Form

OMB No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

Upon Completion E-Mail form to oec@dhs.gov

2.

Overall, were you satisfied with the quality and content of the deliverable?

Please include any additional relevant information:

(SWIC / POC only): Please include any suggestions on how OEC might improve this type of technical assistance for future
deliveries:

Technical Assistance Work Order:
(For OEC Use Only)

DHS Form 9042 (3/10)

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