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KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Thank you for your interest in Klickitat County DEM’s Emergency Management Volunteer Program. These Volunteers support First Responders and assist in coordination of local government’s response to large-scale emergencies and disasters. This work is vital to the safety and well-being of residents of and visitors to Klickitat County; protection of critical infrastructure; and economic recovery. Enclosed, please find: A description of the Emergency Management Volunteer Program A list of Personal Responsibilities of Emergency Workers based upon State Administrative Code An application for the Emergency Management Volunteer Program A background check authorization form Emergency Management Volunteers meet 2 hours each month except during July, August and September. Volunteers must attend a minimum of 6 of the 9 annual meetings and must participate in at least 2 exercises each year. Each Volunteer is required to complete these classes during their first year of membership (ICS-100, ICS-200, ICS-700, ICS-800, G-191 and G-775), as well as an orientation to the Volunteer Program and an orientation to the EOC, itself. These classes and exercises are typically scheduled on meeting nights. An additional 5 hours of annual training and two exercises is required each year thereafter. The training can be obtained during Volunteer Meetings or by choosing desired classes off KCDEM’s Training Program list and/or exercises off the annual Exercise Schedule. Proof of all training is submitted to the Program Coordinator. Successful applicants will be required to complete a Confidentiality Agreement to protect information, of a sensitive nature, that might be encountered during disaster response. Thank you for your interest in the Emergency Management Volunteer Program. Please send completed information to: Emergency Management Program Coordinator, Klickitat County Department of Emergency Management, 199 Industrial Way, Goldendale, WA 98620. Please allow a minimum of 2 weeks for processing of your application. Jeff King, Director Scott Koehler, EM Program Coordinator ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Volunteers are needed to assist Department of Emergency Management (DEM) Staff in organizing, preparing, and operating the County’s Emergency Operations Center (EOC) in Goldendale and performing other tasks during disasters (natural and man-made) and training exercises. The EOC supports First Responders during large- scale incidents & complex training events, and coordinates emergency efforts among city & county jurisdictions. Volunteers commit two-hours, each month, to scheduled classes and drills. They are then “On-Call” for activations. Attendance at unscheduled activities occurs ONLY if the Volunteer is willing and available. That said, there are opportunities to participate in DEM related community events; as well as project work that can be undertaken with the permission of the Program Coordinator or their designee. Volunteers will train one evening per month (Wednesday evening in the first full week of each month). They will help organize and prepare the EOC for 24-hour operation; will operate the EOC (answer phones, talk on public safety radios, provide logistical support to First Responders, plan for multi-day operations, track purchases, etc.) during large-scale emergencies and disaster recovery efforts, and during complex training activities; will issue information to the public, and other local, county, and state government agencies; and staff DEM’s Mobile Command Post. Most of the required training and exercises is provided during the two-hour drills. There are opportunities for participation in other classes and drills, as well. Approved training is provided at no cost to the Volunteers. Volunteers meet in the EOC on the ground floor of the Department of Emergency Management Building at 199 Industrial Way, Goldendale. If you are interested, please submit the required application and background check form to be considered for membership. Successful candidates are required to sign a Confidentiality Agreement to protect private information that may be encountered during emergencies involving service to the public. The opportunities for participation are endless. Almost everybody should be able to find activities and responsibilities that interest them while serving local residents in preparation for/during situations that challenge our community. For more information, please contact Scott Koehler, Emergency Management Program Coordinator, at [EMAIL REDACTED] or [PHONE REDACTED]. ---PAGE BREAK--- WAC 118-04-200 Personal responsibilities of emergency workers. Emergency workers shall be responsible to certify to the authorized officials registering them and using their services that they are aware of and will comply with all applicable responsibilities and requirements set forth in these rules. Emergency workers have the responsibility to notify the on-scene authorized official if they have been using any medical prescription or other drug that has the potential to render them impaired, unfit, or unable to carry out their emergency assignment. Participation by emergency workers in any mission, training event, or other authorized activity while under the influence of or while using narcotics or any illegal controlled substance is prohibited. Participation by emergency workers in any mission, training event, or other authorized activity while under the influence of alcohol is prohibited. Emergency workers participating in any mission, training event, or other authorized activity shall possess a valid operator's license if they are assigned to operate vehicles, vessels, or aircraft during the mission unless specifically directed otherwise by an authorized official in accordance with RCW 38.52.180. All emergency workers driving vehicles to or from a mission must possess a valid driver's license and required insurance. Use of private vehicles, vessels, boats, or aircraft by emergency workers in any mission, training event, or other authorized activity without liability insurance required by chapter 46.29 RCW is prohibited unless specifically directed otherwise by an authorized official in accordance with RCW 38.52.180. Emergency workers shall adhere to all applicable traffic regulations during any mission, training event, or other authorized activity. This provision does not apply to individuals who have completed the emergency vehicle operator course or the emergency vehicle accident prevention course and who are duly authorized under state law to use special driving skills and equipment and who do so at the direction of an authorized official. Emergency workers have the responsibility to comply with all other requirements as determined by the authorized official using their services. When reporting to the scene, emergency workers have the responsibility to inform the on- scene authorized official whether they are mentally and physically fit for their assigned duties. Emergency workers reporting as not fit for currently assigned duties may request a less demanding assignment that is appropriate to their current capabilities. Emergency workers have the responsibility to check in with the appropriate on-scene official and to complete all required recordkeeping and reporting. [Statutory Authority: Chapter 38.52 RCW. WSR 01-02-053, § 118-04-200, filed 12/28/00, effective 1/28/01; WSR 93-23-005 (Order 93-08), § 118-04-200, filed 11/4/93, effective 12/5/93.] ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Application Applicant Instruction Sheet As a necessary condition of consideration for association with the Klickitat County Department of Emergency Management (KCDEM), specific information and documents are required. Failure to provide this information will result in the removal of your application from consideration. If you have concerns about any of the questions, please put “N/A” in the blank and it can be discussed privately with a Program Official. Complete the application and return it to: “Emergency Management Volunteer Program”, along with the following: Recent photograph (passport size or 3” x Copy of a current and valid Driver’s License Copy of your Social Security Card Your application will be kept on file while a background investigation is conducted. You will be notified when this has been completed. The background investigation could take three months or more to complete. The following is a brief summary of the investigation process: Criminal History check—Disqualification for any felony convictions, any misdemeanor convictions within the last five years or other convictions that cause concerns. Driver’s License check—Disqualification for excessive violations in the last five years. Department Records check—Disqualification for negative contacts with Law Enforcement that cause us concerns. Interviews with References and/or Employers Interview with a DEM Representative Final review and approval by the DEM Director Thank you for your interest in joining the Klickitat County Department of Emergency Management’s Volunteer Program. We understand and appreciate the time and effort necessary to complete this application process which is intended to protect the public through maintenance of a high standard of integrity for those who have significant access to information about persons who could be vulnerable during or after suffering, potentially, the worst day of their life. ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Application Date: A. PERSONAL INFORMATION 1. Name: 2. Present Address: 3. Telephone Numbers: Home: Work: Cell: 4. Email address(es): 5. Date of Birth: Place of Birth: 6. Height: Weight: Hair Color: Eye Color: 7. Driver’s License Number: State of Issue: 8. Social Security Number: US Citizen?: 9. Next of Kin: Address: Phone Number(s): 10. List Other Addresses for the past five years: 11. Have you ever been convicted of a crime? No Yes If yes, explain the circumstances: 12. Have you ever been arrested? No Yes If yes, explain the circumstances: 13. Have you ever used: (circle appropriate items) Cocaine LSD Meth Other illegal drugs (list): ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Application Name: Date: Page #2 of 4 B. RECORD OF EDUCATION 14. Do you have a High School diploma? YES NO If no, do you have a GED ? YES NO 15. Did you attend college? YES NO Name of college: Location: Did you graduate ? YES NO When Major: C. SPECIAL SKILLS 16. Do you hold a current First Aid card? YES NO CPR card ? YES NO Expires: Expires: 17. What EOC activities interest you?: (circle all that apply) EOC Prep Efforts Public Education EOC duties Communications Field Ops Recovery Efforts Other activities you can assist with?: 18. Do you have any map experience? YES NO 19. What other skills or qualifications do you possess? 20. Have you ever been associated with other EOCs? NO YES If yes, which agency ? Location: 21. What are your hobbies and special interests? D. MEDICAL HISTORY 22. Do you have any allergies? NO YES. If yes, please list: 23. Do you wear glasses or contacts? NO YES (circle what you use): GLASSES CONTACTS 24. Would over-night operations create health issues for you? NO YES 25. Do you have any disabilities that require accommodation? NO YES If yes, please describe: ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Application Name: Date: Page #3 of 4 E. EMPLOYMENT RECORD 26. Please list your employers, starting with the current or most recent. I am retired. a. Company Name: Years: Address Phone: Supervisor: Reason for leaving: b. Company Name: Years: Address Phone: Supervisor: Reason for leaving: c. Company Name: Years: Address Phone: Supervisor: Reason for leaving: F. MISCELLANEOUS 27. Why do you want to join the Emergency Management Volunteer Program? 28. Please list the names of at least three persons not related to you who know your qualifications and Who may be contacted as references: (no more than two Law Enforcement references): a. Name: Telephone: Address: b. Name: Telephone: Address: c. Name: Telephone: Address: ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program Application Name: Date: Page #4 of 4 29. Any comments you want to include: THE FACTS SET FORTH IN MY APPLICATION FOR EXAMINATION ARE TRUE AND COMPLETE. I UNDERSTAND THAT, IF ACCEPTED FOR MEMBERSHIP, FALSE STATEMENTS ON THIS APPLICATION MAY BE CONSIDERED SUFFICIENT CAUSE FOR DISMISSAL. I UNDERSTAND THAT I HAVE THE RIGHT TO ANSWER OR PROVIDE ADDITIONAL INFORMATION IN THE CASE OF DEROGATORY INFORMATION. Signature of Applicant Date of Signature RETURN COMPLETED APPLICATION TO: EMERGENCY MANAGEMENT VOLUNTEER PROGRAM 199 Industrial Way Goldendale, WA 98620 ---PAGE BREAK--- KLICKITAT COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT Emergency Management Volunteer Program WAIVER AND AUTHORIZATION TO RELEASE INFORMATION To Whom It May Concern: I authorize you to furnish the Klickitat County Department of Emergency Management (KCDEM) or the Klickitat County Sheriff’s Office, when working on behalf of KCDEM with any and all information you have concerning me, including my work record, my reputation, my medical records, and my military service records. Information of a confidential or privileged nature may be included. Your reply will be used to assist the Klickitat County Department of Emergency Management (KCDEM) in determining my qualifications and fitness for duty with the KCDEM’s Emergency Management Volunteer Program. I understand my rights under Title 5, United States Code, Section 5521, the Privacy Act of 1974, and I waive these rights with the understanding that information furnished will be used by the KCDEM in conjunction with employment practices. I hereby release you, your organization, and others from any liability or damage which may result from furnishing the information requested. A photocopy of this authorization shall be as valid as the original. This authorization shall be considered valid only during my tenure with the Klickitat County Department of Emergency Management’s Volunteer Program. After termination of my involvement with the Emergency Management Volunteer Program, this authorization shall no longer be valid. Print Name Signature Date List Other Names You Have Been Known By (including maiden name and prior married names) Address City State ZIP ---PAGE BREAK--- Klickitat County Emergency Management / 911 Services 199 Industrial Way, Goldendale, WA 98620 Fax (509) 773-0362 Jeff King, Director (509) 773-0582 [EMAIL REDACTED] Julie Buck, E911 Coordinator [EMAIL REDACTED] Klickitat County Department of Emergency Management Oath of Confidentiality EMERGENCY MANAGEMENT VOLUNTEER I, do solemnly swear that I am a volunteer with the Klickitat County Department of Emergency Management, and that I recognize the records and information I will be handling may be of a confidential nature. I swear that all private and personal information I encounter in my duties, and in Klickitat County Department of Emergency Management records I encounter, will be kept in the strictest confidence; that I will not discuss this information with anyone, or imply that I am aware of the existence of any particular person’s records or non- public records to which I might have access. I understand that violation of this oath may be subject to criminal prosecution and disbarment from work with the Klickitat County Department of Emergency Management. Dated this of 20__ Signed: Emergency Management Volunteer Approved: Director/Designee