Form

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
- Area Code Phone Number
Date-Time Event Started
/ Month / Day Year
at
: Hour Minutes
Event Type*
Specific Type*
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

	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*
Should be Empty:

This form is to be used when submitting for approved reimbursements for Communications events.