Form DS-5506 LOCAL UNITED STATES CITIZEN SKILLS/RESOURCES SURVEY

OMB Control No. 1405-0188
Expires: XX/XX/20XX
Estimated Burden - 15 minutes

U. S. Department of State

EMBASSIES/CONSULATES OF THE UNITED STATES OF AMERICA

LOCAL UNITED STATES CITIZEN SKILLS/RESOURCES SURVEY
U.S. citizens abroad may possess critical skills and resources invaluable for helping other U.S. citizens 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 or 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

E-mail Address

City

Country

OCCUPATION(S) AND OTHER SKILLS
Please place a check 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 (specify if other)

Law Enforcement
Food Service

Please provide additional details about the skills marked above.

DS-5506
02-2016

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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
(please specify)

Swahili

Asian-based Languages
(please specify)

Tagalog

Bengali

Urdu

Farsi/Dari

Other Languages

German

Yes

No

(If yes, please specify)

Hindi
Latin-based Languages
(please specify)
Russian

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

PASSENGER CAPACITY

TYPE

SHELTER
TYPE
FOOD SERVICE LOCATION

LOCATION

CAPACITY
CAPACITY

Additional Resources or Information

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RESIDENCY STATUS
Please place a check 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.
PURPOSE: The purpose of gathering this information is to identify U.S. citizens residing in a
particular country who may possess critical skills and resources invaluable for helping other
Americans in a time of crisis.
ROUTINE USES: The information on this form may be shared with 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. 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 USC552a (b) ("Conditions of
disclosure"). This information collection is covered by System of Records Notice State-05,
Overseas Citizens Services Records and Other Overseas Records.
DISCLOSURE: Responding to this survey is purely voluntary.

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: CA/OCS/PMO, U.S. Department of State,
SA-17, 10th Floor, Washington, DC 20522-1707.

DS-5506

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