Pitkin County IMT Application and Nomination Form

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

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).
APPLICANT INFORMATION
Applicant Name *
Applicant Home Unit/Agency *
Applicant Job Title *
Applicant Email Address *
example@example.com
Applicant Cell Phone *

EMERGENCY CONTACT INFORMATION

Please provide a contact name and number in the event of an emergency.
Emergency Contact Name *
Emergency Contact Phone # *

ICS POSITION QUALIFICATIONS
Are you CURRENTLY qualified in an ICS position?

Yes No
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 an NWCG or State of Colorado/All Hazards qualification.
Position #1
Position 1 | Effective & Expiration Dates
MM/DD/YYYY - MM/DD/YYY
Position #2
Position 2 | Effective & Expiration Dates
MM/DD/YYYY - MM/DD/YYY

TRAINEE POSITION INFORMATION
Do you have an OPEN ICS position task book for an ICS position?

Yes No
Please list the ICS position(s) for which you are a TRAINEE. You are considered a trainee ONLY if you have an open & current (w/in expiration period) position task book.

You MUST indicate the exact month, day, and year you INITIATED your position task book AND the current percentage of completion below.

Having this accurate information allows the team coordinators to ensure you are exposed to trainee opportunities so that you gain proficiency in a position and qualification.
Trainee Position #1
Trainee Position 1 | Effective Date
Trainee Position 1 | Percentage Complete
Trainee Position #2
Trainee Position 2 | Effective Date
Trainee Position 2 | Percentage Complete
APPLICANT POSITION OR FUNCTION INTEREST

Using the checkboxes below, please indicate the positions within the IMT in which you are interested.
Function or Section Preference (Select 1 or 2):

Planning Operations Logistics Finance Information Safety Liaison

	I Attended This Training
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 WANT to Attend This Training
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

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

Clear
Date *

Month Day Year
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 all-hazards incident management team.

Please enter the Full Name of the Supervisor/Chief and 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.
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Pitkin County Incident Management Team Application and Nomination Form

Signatures / Approval