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Host Community Assessment Request Form

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Host Community*
Point of Contact Name:*
First Last
Point of Contact Phone:*
Point of Contact Email:*
Enter Email Confirm Email
Mailing Address:*
Street Address City State ZIP Code

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PART I: Training Plan and Requests
Covers the cost of personnel participation in REP training from your community, including cost of food, if any. Invoices with training must be accompanied by a roster of participants with the name of the course and date it was held or a copy of the certificate of completion. Online training must be courses identified in the briefing book and may not exceed the maximum hour allowance.
Number of Trainings to be entered
- 0
- 1
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Name of Training
Date Anticipated
MM slash DD slash YYYY
Number of Individuals
Amount Requested*
Add in food and supplies cost.
Name of Training
Date Anticipated
MM slash DD slash YYYY
Number of Individuals
Amount Requested*
Add in food and supplies cost.
Name of Training
Date Anticipated
MM slash DD slash YYYY
Number of Individuals
Amount Requested*
Add in food and supplies cost.
Name of Training
Date Anticipated
MM slash DD slash YYYY
Number of Individuals
Amount Requested*
Add in food and supplies cost.
Name of Training
Date Anticipated
MM slash DD slash YYYY
Number of Individuals
Amount Requested*
Add in food and supplies cost.
Training Plan & Requests Total

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PART II: Drill and Exercise Participation
Covers the cost of personnel participation in REP drills and exercises including food. Drills and Exercise should reflect expenses incurred ONLY individuals from your municipality.
Number of Drills and Exercises
- 0
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Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals Participating
Place of Exercise
Amount Requested for Drill/Exercise*
Add in food and supplies cost.
Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals Participating
Place of Exercise
Amount Requested for Drill/Exercise*
Add in food and supplies cost.
Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals Participating
Place of Exercise
Amount Requested for Drill/Exercise*
Add in food and supplies cost.
Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals Participating
Place of Exercise
Amount Requested for Drill/Exercise*
Add in food and supplies cost.
Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals Participating
Place of Exercise
Amount Requested for Drill/Exercise*
Add in food and supplies cost.
Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals Participating
Place of Exercise
Amount Requested for Drill/Exercise*
Add in food and supplies cost.
Drill & Exercise Total

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Part III: Equipment Requests
Equipment requests are made for any single piece of equipment greater than $2,500. Equipment purchases of $2,500 or less per individual piece of equipment must come from the $13,500 flat rate.
List amount of equipment you are requesting
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Name of Equipment*
Use in REP*
Describe the Equipment's use in REP
Percentage of Total Cost (If Applicable)
Please enter a number from 0 to 100.
Equipment Amount Requested*
Please enter a number greater than or equal to 2500.
Name of Equipment*
Use in REP*
Describe the Equipment's use in REP
Percentage of Total Cost (If Applicable)
Please enter a number from 0 to 100.
Equipment Amount Requested*
Please enter a number greater than or equal to 2500.
Name of Equipment*
Use in REP*
Describe the Equipment's use in REP
Percentage of Total Cost (If Applicable)
Please enter a number from 0 to 100.
Equipment Amount Requested*
Please enter a number greater than or equal to 2500.
Equipment Total

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Assessment Request Total Summary
Flat Rate request:*
Part I: Training request:*
Part II: Drills & Exercises request:*
Part III: Equipment request:*
Total request:*
The totals are calculated from your inputs in each category.
Scope of Service
How would you like to provide the Scope of Service agreement?*
- Upload a file
- Sign electronically
- I will provide the Scope of Service by email or hard copy
Please attach your signed Scope of Service Agreement.*
Max. file size: 1 GB.

Scope of Service Agreement

SEABROOK STATION ASSESSMENT – CLASS 73 (RSA 107-B)

Scope of Performance:
This reimbursement process is issued in accordance with NH RSA 107-B: 2-4, and all applicable federal and state laws, statutes, rules, regulations, policies, and other governing documents.
Funds may be expended for the purpose of maintaining the community’s Radiological Emergency Response Preparedness Program for the Seabrook Station Emergency Planning Zone (EPZ). The period of performance will be state fiscal year (SFY) 2021, from July 1, 2020 through May 30, 2021. (Expenses for Drills, Exercises, and Equipment >$2,500 per item excluded from this agreement.)

Budget:
The total value of this agreement is $13,500.00. Payment will be issued upon receipt and acceptance of adequate documentation of completion of agreement performance requirements.
One-quarter of the awarded flat funding will be distributed upon execution of this agreement and receipt of checklist completion #1. The balance of the flat rate funding will be distributed quarterly thereafter upon satisfactory completion of the checklist activities for each quarter. Quarters will be based upon the State Fiscal Year (July-June).

Reporting:
The Emergency Management Director must complete the activities listed on the Emergency Management Director REP Maintenance Checklist throughout the fiscal year.
The community agrees that all financial and programmatic records, supporting documents, statistical records, and other records associated with this agreement are required to be retained for a period of seven (7) years, beginning on the first day after the final payment under this agreement, or such longer period as is necessary for the resolution of any litigation, claim, negotiation, audit, or any inquiry involving this agreement.

QUARTER CERTIFICATION DUE DATE

#1 July 1st-September 30th October 15

#2 October 1st – December 31st January 15

#3 January 1st – March 31st April 15

#4 April 1st – June 30th June 1*

* Quarter 4 Certification must be returned by June 1st in order to issue reimbursement in the proper fiscal year.

By entering your name, you attest that you have read and agree to abide by the above Scope of Service Agreement.
Name*
Date*
MM slash DD slash YYYY
Hidden
I certify that I am authorized to submit this request form on behalf of the town listed on the first page of the form. I also certify that the Emergency Management Director has reviewed and approved this submission.*
- I Certify
Name of Person Submitting Form*
First Last
Title of Person Submitting Form*
Email*
Enter Email Confirm Email
Comments/Notes

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Upcoming Trainings

Civilian Response to Active Shooter Events (C.R.A.S.E) Training 2/6/24 0830-1130 DOT 7 HAZEN - February 6, 2024
Civilian Response to Active Shooter Events (C.R.A.S.E) Training Concord, NH - February 13, 2024
Civilian Response to Active Shooter Events (C.R.A.S.E) Training 2/15/24 0830-1130 NHFA - February 15, 2024
Civilian Response to Active Shooter Events (C.R.A.S.E) Training 2/21/24 0830-1130 DOT 7 HAZEN - February 21, 2024
Civilian Response to Active Shooter Events (C.R.A.S.E) Training 2/26/24 0830-1130 DOT 7 HAZEN - February 26, 2024
L-0105 Public Information Basics Concord Foundation of Healthy Communities - February 27, 2024
Civilian Response to Active Shooter Events (C.R.A.S.E) Training Keene State - March 20, 2024
L-0105 Public Information Basics Milford - May 7, 2024
Civilian Response to Active Shooter Events (C.R.A.S.E) Training - October 15, 2024
Houses of Worship & Faith Communities Emergency Preparedness Seminar - October 19, 2024

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