Iowa Pipeline Association
Pipeline Awareness & Education Meetings
Emergency Response Capabilities Survey
Agency Information (Please Print)
First Name:
Last Name:
Title:
Designated Rep:
Agency Name:
Area/County of Responsibility:
Agency Address:
City:
State
Zip:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Agency Email:
Non 911 Phone:
Fax:
24 hr Emergency Phone # :
Department Chief:
Chief's Phone:
Agency Type
Fire
- Public Protection Classification (PPC) Rating:
1
2
3
4
5
6
7
8
9
10
N/A
Emergency Planning Committee
Medical
Regulator (Pipeline)
Emergency Response Dispatch
Hazmat
Law Enforcement
Station Type
Fulltime
Volunteer
Fulltime/Volunteer
Industrial
Military
Airport
Other
Total number of personnel:
Fulltime:
Volunteer:
Survey of Emergency Response Capabilities
EQUIPMENT
1. Total number of operational trucks:
Pumper
Tanker
2. Total number of ladders/aerial trucks:
3. Does your agency have firefighting equipment (i.e. foam) suitable for oil, natural gas, liquid petroleum, or any other types of pipeline fires?
Yes
No
N/A
If yes, please list:
4. Can your organization provide, or have access to, air evacuation services?
Yes
No
N/A
5. Does your agency have, or have access to, ambulance services?
Yes
No
N/A
6. Does your agency have, or have access to, earth moving equipment that could be utilized in the event of an emergency?
Yes
No
N/A
MUTUAL AID
1. Does your agency have Mutual Aid Agreements?
Yes
No
N/A
If yes, with whom?
Survey of Emergency Response Capabilities
COMMUNICATIONS
1. Can you communicate by radio on an incident scene with your federal, state, and local emergency response partners?
Yes
No
Don't know
2. Who has primary responsibility for dispatch operations?
Fire Dept.
Police Dept.
Private Company
3. Are your radios safe for operation in a hazardous atmosphere (intrinsically safe)?
Yes
No
Don't know
CAPABILITIES
1. Has your agency ever responded to a pipeline incident?
Yes
No
N/A
2. If a pipeline incident did occur, would your agency respond?
Yes
No
N/A
3. Has your agency performed any practical training (hands on, mock drill, tabletop) on how to respond to a pipeline emergency?
Yes
No
N/A
4. Has your agency received training in regards to pipeline safety prior to this class?
Yes
No
N/A
5. Can your organization assist with traffic control on state and interstate highways?
Yes
No
N/A
6. Can your organization provide medical assistance?
Yes
No
N/A
7. Does your organization have personnel that are trained to fight oil, natural gas, liquid petroleum, and other types of pipeline fires?
Yes
No
N/A
8. Does your organization have personnel that are certified Hazardous Materials/HAZWOPER responders?
Yes
No
N/A
If so, what level?
Awareness
Operational
Technical
9. Can your organization assist with public evacuation?
Yes
No
N/A
10. Does your organization have a plan for public evacuation?
Yes
No
N/A
11. Does your organization have a hazardous spill contingency plan?
Yes
No
N/A
12. Do you feel that your agency has the necessary training for a response in the event of a pipeline emergency?
Yes
No
N/A
13. Can you provide communications and assistance with public evacuation?
Yes
No
N/A
We appreciate and value your input, and in an effort to continuously improve our program, please provide any other information you feel would be beneficial to us. Thank you!
Additional Remarks (Please Print)
FOR ADMINISTRATIVE USE ONLY
Contact Method
Meeting
Face to Face
Mail
Telephone
Fax
Email