Form FEMA Form 119-17-1 FEMA Form 119-17-1 Request For Housing Accommodations

O.M.B. No. 1660-0029
Expires March 31, 2014

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

REQUEST FOR HOUSING ACCOMMODATIONS
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 6 minutes per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the needed data, and completing, and submitting this form. This collection of information is required
to obtain or retain benefits. You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments
regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland
Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0029). NOTE: Do
not send your completed survey to the above address.
PRIVACY ACT STATEMENT
Authority: Public Law 93-498, 15 U.S.CA. 2206, 5 Up. So. CA. 301, 44 Up. So. CA. 3101, 50 Up. So. CA.Ape. 2253, E.O. 12127 and E.O. 12148.
Purpose: This information is being collected for the primary purpose of assigning housing and/or training space at the National Emergency Training Center.
Routine Uses: The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This
includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 011 Training and Exercise Programs System of
Records System of Records Notice (April 6, 2011, 76 FR 19107) and upon written request, by agreement, or as required by law.
Disclosure: The disclosure of information on this form is voluntary; however, failure to provide the information requested may result in the inability to assign/
obtain housing and/or training space. Information such as gender is necessary because the accommodations are of dormitory type and it is required to separate
individuals by gender. Information will only be released as permitted by law.
STATUS
FEMA Employee
Contract Instructor
Contractor
Other Specify
* Must present a copy of travel authorization or invitational travel, if applicable, at the time of registration.
DATE OF ARRIVAL

DATE OF DEPARTURE

NAME OF INDIVIDUAL REQUESTING HOUSING

PURPOSE OF VISIT

IT IS REQUESTED THAT THE FOLLOWING PEOPLE BE PROVIDED HOUSING AT NETC
PERSONAL
INDENTIFICATION
NUMBER

NAME OF INDIVIDUAL

PURCHASE
ORDER NUMBER
(If any)

GENDER
(M/F)

HANDICAPPED
(Y/N)

SPECIAL ACCOMMODATIONS NEEDED

I certify that the housing requested above is accordance with FEMA Instructions covering SIGNATURE (Individual Requesting Housing)
housing policy will be paid with a NETC fee schedule at NETC.
APPROVED
YES

NO

SIGNATURE (NETC Program Office Head or Official Designee)

BILLING INFORMATION USE ONLY

FEMA Form 119-17-1, (3/2011)

SIGNATURE (Director, NETC Management and Operations
designee)

Exempt for payment

Must pay prevailing rate

Housing included in cost

Housing not included in cost

PREVIOUSLY FF 75-10