Community Information
County/City/Town	Population
Primary Point of Contact	Secondary Point of Contact
Name	Name
Office	Office
Title	Title
Mailing Address	Mailing Address
City	City
State; ZIP	State; ZIP
Phone	Phone
e-mail	e-mail
Guideline 1: Communications
Location of 24-Hour Warning Point	Location of Emergency Operations Center

Verification Team General Notes:
Renewal Comments:
Date:	Initials:
Note: Please do not write in shaded areas.
Guideline 2:	NWS Information Reception Equipment
Warning Point # Required_____ # Verif_____	Verif	EOC # Required_____ # Verif_____	Verif
□ NOAA Weather Radio (required if in range)	□	□ NOAA Weather Radio (required if in range)	□
□ NOAA Weather Wire (subscription)	□	□ NOAA Weather Wire (subscription)	□
□ EMWIN	□	□ EMWIN	□
□ Law Enforcement Teletype (LETS)	□	□ Law Enforcement Teletype (LETS)	□
□ Amateur Radio	□	□ Amateur Radio	□
□ Pagers* (warning reception)	□	□ Pagers* (warning reception)	□
□ Television (Local network or Cable TV)	□	□ Television (Local network or Cable TV)	□
□ Radio Station (AM/FM) - EAS Reception	□	□ Radio Station (AM/FM) - EAS Reception	□
□ NAWAS	□	□ NAWAS	□
□ Internet (subscription for alerts)______________	□	□ Internet (subscription for alerts)_____________	□
□ Commercial Data Service_________________	□	□ Commercial Data Service_________________	□
□ Other*_________________________________	□	□ Other*_________________________________	□
□ Other*_________________________________	□	□ Other*_________________________________	□
List any additional capabilities on a separate sheet
*Capabilities needing explanation:
Verification Team Notes:
Renewal Comments:
Date:	Initials:
Note: Please do not write in shaded areas.
Guideline 3:	Local Weather & Water Monitoring Equipment
Warning Point # Required____ # Verif_____	Verif	EOC # Required_____ # Verif_____	Verif
□ Anemometer (Wind gauge)	□	□ Anemometer (Wind gauge)	□
□ Rain Gauge	□	□ Rain Gauge	□
□ River Gauge	□	□ River Gauge	□
□ Locally owned Radar	□	□ Locally owned Radar	□
□ Internet Radar Source _________________	□	□ Internet Radar Source ____________________	□
□ Internet Weather Station _______________	□	□ Internet Weather Station __________________	□
□ TV Radar Source_____________________	□	□ TV Radar Source________________________	□
□ Other* ______________________________	□	□ Other* _________________________________	□
□ Other* ______________________________	□	□ Other* _________________________________	□
List any additional capabilities on a separate sheet
*Capabilities needing explanation:
Verification Team Notes:
Renewal Comments:
Date:	Initials:
Note: Please do not write in shaded areas.
Guideline 4:	Local Warning Dissemination
Warning Point # Required____ # Verif_____	Verifi ed	EOC # Required_____ # Verif_____	Verifi ed
□ Outdoor Warning Siren(s)	□	□ Outdoor Warning Siren(s)	□
□ Cable TV Override	□	□ Cable TV Override	□
□ Plan for Sirens on Emergency Vehicles	□	□ Plan for Sirens on Emergency Vehicles	□
□ Telephone Tree to Critical Facilities	□	□ Telephone Tree to Critical Facilities	□
□ Local Alert Broadcast System*	□	□ Local Alert Broadcast System*	□
□ Local Pager System* (dissemination)	□	□ Local Pager System* (dissemination)	□
□ Coordinated Area-Wide Radio Network*	□	□ Coordinated Area-Wide Radio Network*	□
□ Local Flood Warning System*	□	□ Local Flood Warning System*	□
□ Other*_____________________________	□	□ Other*________________________________	□
□ Other*_____________________________	□	□ Other*________________________________	□
List any additional capabilities on a separate sheet
*Capabilities needing explanation:
Verification Team Notes:
Renewal Comments:
Date:	Initials:
Note: Please do not write in shaded areas.
Local Government-Owned Buildings in Which Public Traffic is Common

Office

Location or Address	Tone Alert NOAA Weather Radio

Verif

Comments
Warning Point	□	□
EOC	□	□
City Hall	□	□
School Superintendent	□	□
□	□
□	□
□	□
□	□
□	□
□	□
□	□
□	□
□	□
□	□
□	□
Verification Team Notes:
Renewal Comments:
Date:	Initials:
Note: Please do not write in shaded areas.
Guideline 5:	Community Preparedness
Annual Safety Talks # Required_____ # Verif_____
Date	Topic	Location	Speaker
1

2

3

4

5

List any additional safety talks on a separate sheet
Weather Radio Purchase Program
Has your community/county developed a program to subsidize the purchase of Specific Area Message Encoder (SAME) equipped Weather Radios for its citizens? (Not required) Yes_____ No______
If yes, provide details:
Other Community Preparedness Activities
Date	Activity	Location	Organizer
1

2

3

4

5

List any additional activities on a separate sheet
Renewal Comments:
Date:	Initials:
Note: Please do not write in shaded areas.

Guideline 6: Administrative Tools/Record keeping	Verif	Renewal Year

Formal Hazardous Weather Operations Plan

Procedure for reporting storm damage to the local National Weather Service Office in real-time

EOC Activation Procedures

Spotter Activation Criteria

Local Warning System(s) Activation Criteria

□ Yes

□ Yes

□ Yes

□ Yes

□ Yes

□

□

□

□

□

□ Yes

□ Yes

□ Yes

□ Yes

□ Yes
Warning Point personnel has authority to activate Warning System (written)	□ Yes	□	□ Yes
Spotter Roster and Training Record	□ Yes
□	□	□ Yes
Last Visit by Emergency Manager to NWS Office	□ Biennial
Last Visit by NWS Officials to Community	□ Annual
Last NWS Spotter Training for Spotters and Dispatchers	□ Biennial
Last NWS Spotter Training Hosted/Co-Hosted (For populations >40,000)	□ Annual
Exercises s	Topic(s):	Date:	□	Date:

Date :

D
List any additional descriptions, narratives, or documentation on a separate sheet
Verification Team Notes:
Renewal Comments:
Date:	Initials:
Signature of Applying Official
Application Submitted by: (print name):
Office:	Title:
Signature:	Date:
NWS Personnel Receiving Application (print name):
Date Received:
Note: Please do not write in shaded areas.

Site Verification Team Signatures
Print Name:
Office:	Title:
Signature:	Date:
Print Name:
Office:	Title:
Signature:	Date:
Print Name:
Office:	Title:
Signature:	Date:
Print Name:
Office:	Title:
Signature:	Date:
Signature in Renewal Year
Application Submitted by: (print name):
Office:	Title:
Signature:	Date:
NWS Personnel Receiving Application (print name):
Date Received: