MUTUAL AID RESOURCE DIRECTORY

QUESTIONNAIRE

FOR THE COUNTY OF

MUTUAL AID ASSOCIATION

AND THE

CITY/VILLAGE OF

(Date)

MUTUAL AID RESOURCE DIRECTORY SURVEY

INSTRUCTIONS

The attached survey should be completed as thoroughly and completely as possible with the information needed for the preparation of your Mutual Aid Resource Directory for your rural fire protection district, community and fire department. If the question does not apply to your particular situation, indicate that fact by placing a "N/A" in the space provided for your answer. Do Not leave the space blank as this could indicate that you forgot to answer the question. If additional space is needed to answer the question, use a separate piece of paper and indicate the question number on it along with your answer. PLEASE PRINT OR TYPE THE INFORMATION REQUESTED. The more information you provide, the more complete your resource directory will be.

When you have completed the survey photocopy it in case it gets lost in the mail and then return it to Emily Wageman at or Region 5/6 EMA, 435 N. Park Ave, Fremont, NE 68025.

Remember, the sooner you return the survey, the sooner your Fire Department will have the use of the results of the survey in the form of a Mutual Aid Resource Directory. Also remember that the more complete the information is, the better the Directory will be. Do your part to make this a successful project for your Fire Department, Rural Fire District, and Mutual Aid Association.

If you need any assistance or have any questions, contact Emily at 402-727-2785 or 1-800-374-7356.

You can start the information gathering process now by completing the following simple questions:

Survey completed by:

Home Telephone: Work Telephone: Cell Phone:

Date Completed:

George J. Teixeira II, Fire Resource Manager,

[402] 472-5870 or [402] 472-2944

Nebraska Forest Service, Fire Control Section, P.O. Box 830815, Lincoln, Neb. 68583-0815

The Nebraska Forest Service Programs abide with the non-discrimination policies of the University of Nebraska.


MUTUAL AID RESOURCE DIRECTORY SURVEY

Answer ALL questions completely. Please PRINT or TYPE all answers.

GENERAL INFORMATION:

1. Complete Fire District name:

2. What county (or counties) is your fire response district within?

3. List each town, with population, in your Fire Response District:

4. What class community is yours? (Check one) No Town(s) Unincorporated Town

Village Second Class City First Class City Metropolitan City

5. What is the Insurance Service Office rating for your town? Fire District?

6. How many square miles (or acres) are in your response area?

7. Are there any Federal/State parks, forests, wildlife areas, etc. in your response area? YES NO If Yes, identify them:

8. What type of terrain best describes your rural fire district:

Rolling Hills Canyons River Bottoms Sandhills Flat Lands Wetlands

9. Circle what best describes the general land use:

Farming Ranching Light Industry Heavy Industry Residential Recreational

10. Identify any rivers or large lakes in the District:

11. Identify the highways in the District:

12. What railroad(s) serve the District? None Burlington-Northern/Santa Fe Union Pacific

Other Name(s):

DEPARTMENT STRUCTURE

1. When was the town fire department organized? Rural fire district?

2. Number of volunteer firefighters: Number of paid firefighters:

3. Does the fire department operate an ambulance/rescue squad/QRT? YES NO (circle which)

Basic Life Support Advanced Life Support Paramedic Other:

4. If the fire department does not operate it, who does?

5. How many members are on the Rescue Squad? How many are EMTs?

6. Are Rescue Squad members also members of the Fire Department? YES NO

7.  If there is no rescue squad, where is the closest one located?

FACILITIES

1. Is there more than one fire station? YES NO If Yes, where is each one?

2. Is fire equipment kept on ranches? YES NO If Yes, complete the following:

Owner/Occupant Name: / Location from nearest town: / Vehicle Type: / Radio #:

FIRE AND EMS VEHICLES

1. Number of each type of vehicle:

a. Town: Aerials Pumpers Tankers/Tenders Utility Trucks

Other (Number and Type)

b. Rural: Grass Rigs Pumpers Tankers/Tenders Utility Trucks

Other (Number and Type)

c. Forestry: 4x2 Pickups 4x4 Pickups 4x2 Tankers/Tenders

4x4 Tankers/Tenders 6x6 Tankers/Tenders Other (Number and Type)

2. How many ambulance/rescue units are there? QRT Units?

3. List the Emergency Medical Vehicles by Type and Number (even if it is not operated by the Fire Department):

COMMUNICATIONS

1. What is your telephone Area Code Number (check one)? 308 402 Other

2. Is 9-1-1 used? YES NO

3.  What is the emergency SEVEN-DIGIT phone number for the Fire Department? N/A

4. What is the non-emergency telephone number for the fire station? Not Applicable

5. What is the business/fire station (non-emergency) telephone number? Not Applicable

6. What is the emergency SEVEN-DIGIT phone number for the ambulance? N/A

7. What is the business (non-emergency) phone number for the ambulance? N/A

8. If 911 is used, what is the telephone number of the Communications Center?

9. Who answers 911?

10. How are firefighters notified? Fire Siren Pager Telephone Other:

11. Does the fire department have a base radio? YES NO

What VHF lowband frequencies are used? 39.90 (sheriff) 39.98 (fire) 39.82 (medical)

Other (list them):

12. What is the Primary Frequency for VHF High Band (150 mHz) UHF (450/460 MHz)

13. Fire/EMS Primary Frequency:; Alternate(s):

Law Enforcement Primary Frequency: ; Alternate(s):

Hospital: Primary Frequency: ; Alternate(s):

Others (usage): Primary: ; Alternate(s):

14. Are any town radios manned 24 hours a day? YES NO Where?

If No, who operates 24/7?

15. Are all of the fire/rescue vehicles radio equipped? YES NO

SPECIALTY TEAMS

1. Does the fire department have any of these specialized teams? If No, where is each closest team?

Critical Incident Stress Management Team? YES NO Nearest team

Confined Space Rescue Team? YES NO Nearest team

Farm Equipment Extrication Team? YES NO Nearest team

HazMat Response Team? YES NO Nearest team

High Angle Rescue Team? YES NO Nearest team

Rope Rescue Team? YES NO Nearest team

Water Rescue/Recovery Team? YES NO Nearest team

2. Are there any other specialized teams? YES NO If Yes, what?

3. What is the highest level of HazMat training for your fire department? Awareness Level

Operations level Technician level Other

WATER SUPPLIES

1. Is there a municipal water supply in the community? YES NO

2. If there is no municipal water system, where is water available for fire protection?

3. How many wells supply the community and what is the capacity of each?

1 — gpm 4 — gpm 7 — gpm 10 — gpm 13 — gpm

2 — gpm 5 — gpm 8 — gpm 11 — gpm 14 — gpm

3 — gpm 6 — gpm 9 — gpm 12 — gpm 15 — gpm

4. Identify by number each of the above wells with emergency power:

5. If water is not supplied by wells, what is the water source?

6. What type of storage is there? None Water Tower Underground Other

7. What is the system storage capacity? gallons. Recovery rate? gpm

8. How many fire hydrants are on the system? What size are the discharges?

9. Is there a swimming pool(s) which can be used for a water source? YES NO. Where is each located?

10. Can tankers/tenders be filled from an overhead source? YES NO Where?

11. Is there a rural water system with hydrants? YES NO If yes, identify the locations below:

Hydrant / Location from Nearest Town:
1
2
3
4
5
6
7
8
9

12. Identify any other reliable rural water sources? (Irrigation wells, stock tanks, ponds, lakes, etc.)

Type Source: / Location from Nearest Town:

II — AREAS REQUIRING MUTUAL AID

These are areas or facilities which due to the nature of the construction, occupancy or contents could present a special problem or hazard in the event of a fire and to which mutual aid would probably be required.

MUTUAL AID AREAS
Facility Name / Type Occupancy / Street Address / Nearest Water

III — PERSONNEL ROSTERS PRINT OR TYPE

Title / Name / Home/Cell Phone / Work Phone
Rural Fire District Board of Directors
President
Vice President
Secretary/Treasurer
Director
Director
Director
City Council or Village Board
Mayor/Chairman
Member
Member
Member
Member
Member
Member
City/Village Clerk
Fire Department/EMS Officers
Fire Chief
Assistant Chief
Assistant Chief
Training Chief
EMS Chief
Captain
Captain
EMS Captain
President
Vice President
Secretary
Treasurer

IV — RESOURCES (Fill in a name, if required, and telephone numbers of the resource)

DO NOT use 9-1-1 — Use a seven-digit telephone number (123-4567).
If the fire department or rescue squad does not have a seven digit telephone number use the 24-hour
telephone number of the dispatch center which dispatches the fire department and rescue squad.
RESOURCE NAME / FIRE / RESCUE
Emergency
Business
Fire Station
911 Communications Center Location:
911 Center Ten-Digit Telephone Number (include Area Code):
Fire Departments Bordering your Fire Response District:
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
Emergency
Fire Station
EMERGENCY MEDICAL RESOURCES
Hospitals / Town / Encode #/Frequency / Telephone
Other Local Medical Resources
Local and State Agencies / Town / Day Phone / Night Phone
Police Department
Sheriff's Department
State Patrol (Local Troop)
Deputy Fire Marshal
Emergency Management (Town)
Emergency Management (County)
COMMUNITY RESOURCES
Resource Name / Town / Day Phone / Night Phone
Electric Companies…
City Electric Department
Excavation Equipment:
City Street Department
Nebraska Department of Roads
County Highway Department
Private Contractors
Fuel Suppliers (Service Stations)
Fuel Suppliers (Delivery Service):
Natural Gas Companies:
Pipeline Companies:
Propane Companies:
`
Railroads:
School Buses:
Telephone Companies:
Water Companies:
City Water Department
Rural Water District
Water Trucks:
Wreckers:

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V - EQUIPMENT INVENTORY:

Radio
No.: / Year and Make: / Pump
GPM / Tank
Size / SCBA
Packs: / Fire Hose — Size and Number of Feet:
1" / 11/2" / 13/4" / 21/2" / 3" / 4" / 5" / 6"
4x4 Grass Trucks
Pumpers
4x2 Tankers/Tenders
4x4 and 6x6 Tankers/Tenders
Aerial Ladders, Telescoping Aerials, Snorkel Trucks
Equipment / Utility Trucks and Vans
Other Vehicles (Boats, Trailers, Airplanes, etc.)
Ambulances & Rescue Squads
Radio No.: / Year and Make: / Patient Capacity: / Radio No.: / Year and Make: / Patient Capacity:
Non-transport EMS Units:
Radio No. / Year and Make: / Radio No. / Year and Make:

Portable Equipment (Indicate the number of each item

Item / Qty: / Item / Qty: / Qty: / Item: / Qty: / Qty: / Item: / Qty:
Air Bags / Hose (Feet) / Suction (Feet) / Stretcher, Hard Backboard
Air Cascade (SCBA) / 1½" / 2½" / 1½" Straight / 1½" Comb. / Stretcher, Folding (Army)
Air Chisel / 1¾" / 4" / 2½" Straight / 2½" Comb. / Stretcher, Stokes
Air Compressor (SCBA) / 2½" / 4½" / Cellar / 1½" Foam / Suit, Aircraft Proximity
Air Packs (SCBA) / 3" / 5" / Piercing / 2½" Foam / Suit, HazMat
Air Tanks (SCBA), extra / 4" / 6" / 500 gpm Combination Nozzle / TRIAGE First Aid Kit
Cutting Torch / 5" / 1,000 gpm Combination Nozzle / Water Tank, Portable
Diving Suits / 6" / Water Curtain Nozzle / Water Tank Syphon
Diving Tanks / Hydraulic Rescue Jaws / Pike Poles: / Wildfire Tool (Polaski)
Fan, Exhaust / Hydraulic Rescue Rams / 6 foot / 12 foot / Other Misc. Equipment:
Fan, Positive Pressure / Hydraulic Rescue Shear / 8 foot / 14 foot
First Aid Kit, FD Type / Ladders (Number): / 10 foot / 16 foot
Floodlights / 6' / 8' Step / 20’ roof / Port-A-Power
Foam (Gallons): / 10' Folding / 24' ext / Pump, Portable
AFFF / Alcohol / 12' Folding / 26' ext / Pump, Portable Floating
Class A / Class B / 12' Straight / 28' ext / Radio, Portable
Hi-Exp. / Protein / 14' Straight / 35' ext / Salvage Cover
Foam, Eductor / 16' Roof / 40' ext / Saw, Chain
Foam Generator (Hi-Exp) / 18' Roof / 50' ext / Saw, Forcible Entry (K-12)
Generato(Portable Electric) / Irrigation Well Adaptor / Saw, Recipro-cating

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VI -Additional Information - Provide any additional information, material, maps, etc., that you feel should be included in your Mutual Aid Resource Directory.

How many large (8½"x11") Mutual Aid Directories do you want?

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