Pitkin County IMT Application and Nomination Form

Supervisor/Chief - Approval / Denial

** Special note about mutual aid and reimbursable incidents:A majority of the incidents to which the Pitkin County Type IMT will be deployed are considered mutual aid and will follow protocols established in the Local Annual Operating Plans, or other mutual aid agreements. However, some incidents may be eligible for reimbursement depending on ownership and/or disaster declaration. In these cases, payment procedures will be established at the time of the incident.

Supervisor/Chief Signature

Clear

Pitkin County Incident Management Team Application and Nomination Form

All individuals applying for positions on the Pitkin County Incident Management Team or trainee positions must submit this nomination form.

Current PCIMT members are required to submit this form to ensure correct personal information and to secure permission from your home agency.

The applicant's supervisor / Chief must approve all nominations. Some Units may require a second level of approval (i.e. Fire Chief; Forest / Park FMO or State).

Name *

Home Unit/Department *

Job Title *

Email Address *

example@example.com

Cell Phone *

Emergency Contact Name *

Emergency Contact Phone # *

Qualifications:

Please list the ICS position(s) for which you are qualified (have a completed taskbook). Be sure to note the exact month, day and year of effective and expiration dates. Also note if it is a NWCG or FEMA / Colorado All Hazards.

Position #1

Effective & Expiration Dates

MM/DD/YYYY - MM/DD/YYY

Position #2

Effective & Expiration Dates

MM/DD/YYYY - MM/DD/YYY

Trainee Positions:

If you have an open taskbook as a trainee please indicate what percentage of the tasks are completed.

Trainee Position #1

Effective Date

Percentage Complete

Trainee Position #2

Effective Date

Percentage Complete

Function or Section Preference (Select 1 or 2):

Planning Operations Logistics Finance Information Safety Liaison Other

NWCG Fitness Level (check one - required field)

Arduous Moderate Light None

Date of test

Date

Who administered the test?

Location

Training Needs Assessment:

Please mark the below listed courses you have attended and the date. If you attended a wildland (NWCG) equivalent course please mark it in the All-Hazards course area. The course number may be an L, E or P listing; AH stands for All-Hazard. If you would like to attend the course mark that box.

Training Needs Assessment

	Attended	Date	Place	Want to Attend
L-950 AH Incident Commander
L-958 AH Operations Section Chief
L-962 AH Planning Section Chief
L-967 AH Logistics Section Chief
L-973 AH Finance/Adm Section Chief
L-956 AH Liaison Officer Course
L-952 AH Public Information Officer
L-954 AH Safety Officer Course
L-965 AH Resource Unit Leader
L-964 AH Situation Unit Leader
L-969 AH Communications Unit Leader
L-970 AH Supply Unit Leader
L-971 AH Facilities Unit Leader
L-975 AH Finance/Adm Unit Leader
L-960 AH Division/Group Supervisor
L-381 Incident Leadership - 5 Days
L-380 Incident Leadership - 4 Days
S-420 Command & General Staff - 5 Days
I-100 Introduction to ICS (online)
I-200 Basic ICS (online)
I-300 Intermediate ICS
I-400 Advanced ICS
IS-700a NIMS an Introduction (online)
IS-800b NRF an Introduction (online)
G191 EOC/IMT Interface

I am currently listed in ROSS by MY HOME AGENCY:

Yes No

If yes, what dispatch center?

Consideration for special assignment opportunities

Yes, I am willing to be considered for National call-outs assignments EMAC on a case by case basis. Usually 14 day assignments plus travel time. No, I am not able to participate outside of the Northwest Region.

If yes, what is your Salary Rate per Hour?

If yes, what is your Overtime Rate per Hour?

If yes, what is your Benefits Rate per Hour?

IMT Applicant Signature - To the best of my knowledge all identified qualifications and experience records are accurate. *

Clear

Date *

Date

The applicant must provide the permission of their supervisor / Chief who has the authority to allow them to be away from their daily assignment for extended times. The applicant will be expected to attend assignments and team training to develop their skills as members of this regional AHIMT.

Please enter the Full Name of the Supervisor/Chief as well as their email so that the completed form can be automatically emailed to them for approval.

Supervisor/Chief Full Name *

Supervisor/Chief Email Address *

example@example.com

Alex Burchetta Email

example@example.com

I concur with the goals, commitment, and availability of the applicant for disaster/emergency assignments as a member of the Pitkin County Incident Management Team. The applicant has permission to leave their work assignment to participate. I also certify that the participant's basic insurance requirements (including but not limited to worker's compensation and liability) are covered by their home agency.

** Special note about mutual aid and reimbursable incidents:

A majority of the incidents to which the Pitkin County Type IMT will be deployed are considered mutual aid and will follow protocols established in the Local Annual Operating Plans, or other mutual aid agreements. However, some incidents may be eligible for reimbursement depending on ownership and/or disaster declaration. In these cases, payment procedures will be established at the time of the incident.

Pitkin County Incident Management Team Application and Nomination Form

Signatures / Approval