This form is to be used when submitting for approved reimbursements for Communications events.
Full Name
*
First Name
Last Name
Town-County
*
Town
County
Agency/Jurisdiction
Agency
Jurisdiction
E-mail
*
Phone Number
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Area Code
Phone Number
Date-Time Event Started
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Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event Type
*
Please Select
Incident
Planned Event
Exercise
Specific Type
*
Please Select
Active Shooter
Fire
Hazmat
Large Crowd Event
Mass Casualty
Mass Fatality
Natural Disaster
Suspicious Package
Other
If Other, please specify
Click Jurisdictions involved in event
*
Local Fire
Local EMS
Local LE
State LE
County LE
Federal Entity
Tribal
Other
If Other, please specifiy
Select the types of communications equipment used in the event.
*
Cellular Phone
Satellite Phone
Land Lines
Radio
Ham Radio
Internet
PDA
Marine Radio
Aviation Radio
FLIR System
Other
If other, please specify
What types of mobile equipment were used?
Mobile Command Vehicle
County Communications Vehicle
Mobile Repeater/Tower
Select any of the following that were used during the event.
Comm. Plans
County EOC
CONOPS
ICS Form 205
Incident Comm
State EOC
Comm. Tech
Unified Comm.
Select the following if appropriate
After Action Report filed through HSEEP
Dispatch Radio Logs written
ICS 201 Form
Did you identify equipment failures? If yes, indicate the issues and propose resolution
Did you identify ICS issues? If yes, indicate the issues and proposed resolution.
Who was the first person on the scene? Did this person become the Incident Commander? If not, how long before someone was designated the IC?
How long before the incident was under control?
Did you identify protocol issues? If yes, please explain the issue and proposed resolution.
Was the IC able to communicate with the necessary people within one hour? If not, how long
*
Was plain language used?
Were common channel names used by all responding agencies?
Was there any overload on communications systems?
Was the Incident Commander able to communicate with first level entities within one hour? If not, how long?
*
Communications Capabilities
Rows
Worked Very Well
Somewhat Well
Not very well
Not at all
Policies and Procedures
Responder Roles and responsibilities
Communications Equipment
Provide 3 success factors
*
Provide 3 areas of improvement
*
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