DCS-22 Contact / Capabilities Survey

This form is intended for use by registered members of DCS-22 to assist in maintaining current information regarding how you may be contacted and your capabilities / availability. Please complete the following questionaire supplying all of the information you can. You may also use this form to report changes in information previously supplied.

Information supplied on this form is subject to the DCS-22 Privacy Policy and will not be provided or sold to any other agency, group, or individual. Completion and submittal of this form indicates acceptance of this policy and grants DCS-22 authority to use the data accordingly. Questions regarding the privacy of personal data should be directed to K-001.

* Required Information

	Version 2.05	Personal Data
*	Amateur Callsign:
	License Class:	Extra Advanced General Tech Plus Technician Novice
	License Expires:	mm/dd/yy
*	DCS-22 Unit Identifier:	K-### Number:
*	eMail Address:
*	Last Name:
*	First Name:
	Middle Initial:
	Nick Name:
*	Is this an update to a prior Registration?	Yes No
	Mailing Address:
	City:
	State:
	Zip Code:
	Telephone Numbers:	Home: Work: Ext: Mobile/Cell: FAX: Pager:
	Primary Frequency Monitored:	MHz.
	Employment:	Employer: City: eMail:
	Preferred Method of Contact:	Home Telephone Mobile/Cell Telephone Pager Work Telephone Other:
	Notify in Emergency:	Name: Telephone Number(s): Relationship:
	Do you have any Special Medical Condition?	No Yes - Explain
	Normal Availability Hours: Please indicate those hours you are most likely to be available Monday through Friday.	0001-0600 0601-1200 1201-1800 1801-2400 Other

		Transportation Check those that apply
	Vehicles Available for Emergency Use:	Car Pick-up SUV Van ATV Other
	Drivers License:	Valid US Drivers License LASD Trained DCS-22 Van Training Other

		Emergency Preparedness Training Check only those that apply and are current
		LASD Basic DCS LASD Traffic LASD Shadow Operator LASD Officer Safety for Volunteers FEMA IS-100 - Intro to ICS FEMA IS-111 - Livestock in Disasters FEMA IS-200 - ICS for Small Resource Incidents FEMA IS-700 - Intro to NIMS CERT CPR First Aid CHP Traffic LA Fire Licensed Medical Personnel HASMAT Other

		Equipment Availability Check only equipment in operting condition
	Home (Fixed) Station;	75-10 Meters 6 Meters 2 Meters 222 MHz 440 MHz 1.2 GHz ATV CB 11 Meters Family Radio Service Other
	Mobile (Installed or Portable):	75-10 Meters 6 Meters 2 Meters 222 MHz 440 MHz 1.2 GHz ATV CB 11 Meters Family Radio Service Other
	Handheld:	6 Meters 2 Meters 222 MHz 440 MHz 1.2 GHz ATV CB 11 Meters Family Radio Service Other
	Emergency Power:	Home Generator KW Portable Generator KW Portable 12V Battery Other KW
	Portable Antennas:	HF: HF Vert HF Beam HF Wire Ant - Bands 6M: Vert Beam 2M: Vert Beam 222MHz: Vert Beam 440MHz: Vert Beam 1.2GHz: Vert Beam Other: (Describe)

		Capabilities Check the level of your ability/interest
	Message Handling Experience:	None Low Medium High
	Directing Other People:	None Low Medium High
	Working at Night:	None Low Medium High
	Electronic Repair Experience:	None Low Medium High
	Ability to Install Antennas:	None Low Medium High
	HF Experience:	None Low Medium High
	Programming HT's:	None Low Medium High
	Willingness to do non-radio tasks:	None Low Medium High
	Generator Experience:	None Low Medium High
	Telephone Experience:	None Low Medium High
	Computer Skills:	None Low Medium High
	Sign Language:	Yes No
	Languages:	Read Speak Read Speak
	Please list any additional skills here:

	Other Comments:

	Do you want to receive DCS-22 Bulletins via eMail?	Yes No
	Do you want to receive the DCS-22 Newsletter via eMail?	Yes No