Form DHS-9043 OEC Technical Assistance (TA) and SCIP Workshop Rquest F

DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications

OMB No. 1670-0023
Expiration Date: 10/31/2014

Technical Assistance (TA) and
Statewide Communications Interoperability Plan (SCIP) Workshop
Request Form

Instructions
Read all ins tructions before com pleting this form .

Privacy Act Statement
Authority: Title XVIII of the Hom eland Security Act of 2002, 6
U.S.C. § 101 et s eq., and the Im plem enting Recommendations
of the 9/11 Com m is s ion Act or 2007 (6 U.S.C. 579(m )
authorizes the collection of this inform ation.
Purpose: The prim ary purpos e of this collection is to collate
reques ts for technical as s is tance and evaluate the im pact of
reques ts on the attainm ent of the National Em ergency
Com m unications Plan’s goals , objectives , and initiatives .
Routine Uses: The inform ation collected m ay be dis clos ed as
generally perm itted under 5 U.S.C. § 552a(b) of the Privacy Act
of 1974, as am ended. This includes us ing the inform ation as
neces s ary and authorized by the routine us es publis hed in
DHS/All-002 Mailing and Other Lis ts Records Sys tem of
Records (Novem ber 28, 2008, 73 FR 71659).
Disclosure: Providing this inform ation is voluntary, however,
failure to provide this inform ation m ay delay or prevent the
Office of Em ergency Com m unications in its ability to determ ine
res ources available to provide technical as s is tance s ervices to
the juris diction.

What is the purpose of filling out this Form?

Filling out DHS Form 9043
Requestor Contact Information
This s ection of the form is typically com pleted by the SWIC, SCIP
POC or the State/Territory level official whom OEC can contact to
clarify the goals and purpos es of the reques ted Works hop and/or
TA s ervice offering and who will s erve as the point of contact with
OEC.
OEC Coordinator Contact Information
This pull-down s election provides contact inform ation for the OEC
Coordinator as s igned to the State/Territory, who can be contacted
for further inform ation about OEC.
Statewide Communications Interoperability Plan (SCIP)
Implementation Workshop Requests
For FY2015, OEC/ICTAP is accepting SCIP Works hop reques ts
focus ed on the following categories : SCIP Update, Governance,
Technology, Funding, Broadband / NG-9-1-1 and Other that
com plem ent the
State/Territories
Technical
As s is tance
requirem ents .
Technical Assistance Requests
This part of the form contains two s ub-s ections :

1) Individual technical as s is tance reques ts , Priority 1 – 5
DHS Form 9043, Office of Em ergency Com m unications (OEC)
2) Signatures and s ubm is s ion date
SCIP Im plem entation Works hop and Technical As s istance (TA)
Individual Requests
Reques t Form , is us ed by States and Territories , to reques t
Priority:
Reques tors s hould us e the colum ns labeled "Priority" and
SCIP Works hops and TA s ervice offerings from the OEC
"Des
cription
of As s is tance" to identify up to five areas in which
Technical As s is tance Catalog.
they require OEC TA, lis ting them in des cending order of
Reques ts for SCIP Works hops and Technical As s is tance im portance, 1 - 5.
Service Offerings s hould com plem ent each other and m ay be
s ubm itted together or s eparately. OEC will cons ider reques ts Des cription of As s is tance: Include in this block a brief des cription
bas ed on the priority indicated by the State as well as the of the is s ue or challenge for which TA is needed; s om e notional
anticipated im pact of the s ervice offering on the im plem entation exam ples m ight be:
of the National Em ergency Com m unications Plan (NECP) and
– "Develop a field operations guide for State's /Territories ”
the res pective Statewide Com m unications Interoperability Plan
– "Help State plan for the NPSBN im plem entation"
(SCIP).
– "Develop and m aintain a cadre of COML pers onnel"
Form s s hould be com pleted by the State/Territory’s Statewide
TA Offering: Under this colum n, us e the pull down s election to
Interoperability Coordinator (SWIC) or SCIP point of contact identify the TA s ervice offering code whos e des cription in the
and s ent to OEC through the Public Safety Tools web s ite at: Catalog m atches the requirem ent. For exam ple, the codes
www.publics afetytools .info.
corres ponding to the above notional exam ples are:
– TIC-FOG
– BB-BRND101

– TRG-COML
– CASM-UPDATE

Paperwork Reduction Act Notice. The public reporting burden to complete this inf ormation collection is estimated at 25 minutes per response, including time f or rev iewing
instructions, searching data sources, gathering and maintaining the data needed, and the completing and rev iewing the collected inf ormation. An agency may not conduct
or sponsor, and a person is not required to respond to a collection of inf ormation unless it display s a currently v alid OMB control number and expiration date. Send
comments regarding this burden estimate or any other aspect of this collection inf ormation, including suggestions f or reducing this burden to DHS / National Protection and
Programs Directorate/Of f ice of Cy bersecurity and Communications/Of f ice of Emergency Communications, Serena Maxey , 703-235-4090,serena.m ax ey @hq.dhs.gov ,
ATTN: PRA [1670-0023].

DHS For m 9043 (7/13)

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DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications

OMB No. 1670-0023
Expiration Date: 10/31/2014

Technical Assistance (TA) and
Statewide Communications Interoperability Plan (SCIP) Workshop
Request Form

Tim efram e From /To: Enter a 30 to 90 day tim efram e during the
com ing year in which OEC could deliver the TA offering. This
inform ation helps OEC align its res ources to optim ize delivery
of m ultiple TA offerings acros s the Nation.
Prim ary Point of Contact (Nam e, Phone, Em ail): Enter the
nam e and contact inform ation for the individual whom OEC
s hould contact to arrange s cheduling, logis tics and other
adm inis trative as pects of the TA delivery. This individual m ay
be different from the SWIC.
SWIC / SCIP POC Signature: The SWIC or the point of contact
for the State's SCIP s hould “s ign” the form by entering his /her
nam e and contact inform ation.
State Adm inis trative Agency (SAA): The SAA s hould
counters ign the form to indicate concurrence with the individual
technical as s is tance reques ts from the s tandpoint of grants .
This coordination m ay be entered by the SWIC.
Subm is s ion Date: Date the form is s ubm itted to OEC by the
State/ Territory.

Continuation Sheet

Provide any additional background inform ation or details about
the reques ted TA. Als o, you can us e this s ection to des cribe
your interoperable em ergency com m unications is s ues or
challenges that do not appear to be covered by the s ervice
offerings in the Catalog.
An interactive vers ion of this form m ay be acces s ed at
www.publics afetytools .info. The com pleted form will be
autom atically s ent to OEC with a copy to the reques tor.
Scanned vers ions as attachm ents and/or any ques tions about
this form m ay be em ailed to: oec@dhs .gov

DHS For m 9043 (7/13)

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DEPARTMENT OF HOMELAND SECURITY
OMB No. 1670-0023
Expiration Date: 10/31/2014

Office of Emergency Communications

Technical Assistance (TA) and
Statewide Communications Interoperability Plan (SCIP) Workshop
Request Form

Technical Assistance and SCIP Workshop requests can be submitted
by accessing the online form located on the
Public Safety Tools site: www.publicsafetytools.info or
by scanning this completed form and emailing it to:
TARequest@hq.dhs.gov

(Requestor) Contact Information:
State:
Name:
Phone:
Email:

OEC Coordinator:

SCIP Workshop Section:
Priority

SCIP Workshop Focus

Please Provide Additional Background or Details

SCIP Update
Governance
Funding
Technology
Broadband & NG9-1-1
Other

Requester’s target date range for SCIP Workshop:

DHS For m 9043 (7/13)

From:

To:

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DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications

OMB No. 1670-0023
Expiration Date: 10/31/2014

Technical Assistance (TA) and
Statewide Communications Interoperability Plan (SCIP) Workshop
Request Form

Prioritized TA Selections
Pleas e indicate each TA Catalog s ervice offering reques ted in order of priority. For FY2015, OEC/ICTAP is cons idering
reques ts in s upport of the SCIP im plem entation initiatives for m ulti-state collaboration and preparedness. SWICs are
encouraged to lis t reques ts pertaining to thos e areas as numbers 1 and 2 on this form .

Priority

Description of Assistance

TA Offering

Timeframe
From / To

Primary Point of Contact
(Name, Phone, Email)

1
2
3
4
5

SWIC / SCIP POC

State Adm inistrative Agency

Subm is sion Date

DHS For m 9043 (7/13)

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DEPARTMENT OF HOMELAND SECURITY

Office of Emergency Communications

OMB No. 1670-0023
Expiration Date: 10/31/2014

Technical Assistance (TA) and
Statewide Communications Interoperability Plan (SCIP) Workshop
Request Form

CONTINUATION SHEET – TA REQUEST FORM
Pleas e Provide Additional Background or Details about thes e Requests (Corresponding to the Res pective Reques t Num ber).

Priority

Description of Assistanc e

1

2

3

4

5

DHS For m 9043 (7/13)

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