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State Agency Assessment Request

Step 1 of 7

14%

Affiliation (agency):*
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: Facility Maintenance
(rent, trash removal, electric bills, etc.)
Amount requested:*
% of Total Cost*
Please enter a number less than or equal to 100.
Notes:
Total Facility Maintenance request:

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Part II: Purchase of Equipment
Equipment requests are made for any single piece of equipment greater than $2,500. Identify each piece of equipment separately.
Select amount of equipment requests:*
- 0
- 1
- 2
- 3
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.
Total Equipment request:*

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Part III: Exercise, Meeting, and Training Participation
Cost of personnel participation in training and exercises. Training requests must be accompanied by a training roster with name of class, date and participants or copy of completion certification. Online training must be courses identified in the Briefing Book and for no more than maximum hour allowance. Training and exercise requests must include individuals’ names. All requests must be related specifically to REP. Requests for quarterly meetings are captured in this category.
Number of activities to be entered:*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Please attach any supporting docs (payroll, rosters, etc.)
Drop files here or

Max. file size: 1 GB.
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Name of Activity*
Date Anticipated*
MM slash DD slash YYYY
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Amount Requested*
Total Exercise, Meeting, and Training Participation request:*

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Part IV: Supplies and Services
Includes: supplies for training, food, postage, telephones, etc.
Number of items requested:*
- 0
- 1
- 2
- 3
- 4
- 5
Supplies and services item:*
Use in REP:*
Amount requested:*
Supplies and services item:*
Use in REP:*
Amount requested:*
Supplies and services item:*
Use in REP:*
Amount requested:*
Supplies and services item:*
Use in REP:*
Amount requested:*
Supplies and services item:*
Use in REP:*
Amount requested:*
Total Supplies and Services request:

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Part V: Planning and Administration
Number of hours expended for overall planning, including annual review and update, and administration of the REP program. Includes special duties required by REP such as inventory control, REP exercise preparation, etc.
Amount Requested:*
Number of Meetings*
Number of Individuals*
Hourly Rate (average)*
Number of Hours*
Total Planning and Administration request:

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Part I: Facility Maintenance request:
Part II: Purchase of Equipment request:
Part III: Exercise, Meeting, and Training Participation request:
Part IV: Supplies and Services request:
Part V: Planning and Administration request:
Total request:*
I certify that I am authorized to submit this request form on behalf of the New Hampshire state agency stated in this request.*
- 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 Concord, NH - January 30, 2024
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
G0402 National Incident Management System Overview for Senior Officials (Executives, Elected, & Appointed) DOC (Closed Class) - May 2, 2024
Crypto 101 Law Enforcement Only - May 2, 2024

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