Ham Radio Questionnaire

Miami-Dade APRSC

At the request of the RACES Officer (Carl, KA4HLO), I'm building a detailed database of active local hams.   Please do me a favor and fill out this form.  This data will go into a database that will be on file at the Miami-Dade EOC.   I know it's a lot to fill out, but it's important that we as much information as possible.  If you need to look up something, fill out as much as you can now, then e-mail me the update later.   If you're not comfortable answering some of these questions, I totally understand.   Free free to leave anything blank.   Some answers are pre-filled in.  If the default answer isn't correct for you, just type over it.  

Thanks,  Ray KD4BBM

South Florida Amateur Radio Operator Questionnaire

Call Sign Prefix (before the digit) Call Sign Digit Call Sign Suffix (after the digit)

License Class:     HF Privileges?      Gender:    Height:

Name, First: Last: Middle Initial: Nickname: 

Address Line 1:  

Address Line 2:  

City: State:  State (2 digit postal Code)    Zip Code: - 

primary e-mail address

paging e-mail address (e-mail here goes to your cell phone or pager;  any e-mail you get on your person, rather than at home or work.  This would be used only for emergency activations.)

Personal Web site       In SoFlaHams mailing list?

Home Phone     Work Phone

Cell Phone        Pager

Work Fax            Home Fax

Nextel Pvt ID (include the * characters)

Your home will need to evacuate in which category hurricane? 

Emergency Contact Data:

Name:    Number:   Relationship:

Your Job Description:    Retired:   (fill in Job Description with your last job)

Current Club/Organization Memberships:

SFFMA    Dade Radio    DCAT    APRSC    CERT    Everglades    FARC    SkyWarn    America Radio Club    Magic City    QCWA    ARRL    VE   REACT    CG RACES/ARES    Red Cross    Hollywood    UMARC 

Other clubs

Positions held in clubs:

Trustee or owner of which repeaters? 

Radio equipment that you own and can use regularly:

Band Portable Mobile Base
HF (any)
50 MHz (6m)
144 MHz (2m)
220 MHz
440 MHz
900 MHz
1200 MHz
2400 MHz
EDACS 800 Miami-Dade Trunking 
800 MHz Conventional
470 MHz T Band
CB
GMRS
Marine
FRS
GPS
APRS Tracker
Packet
Satellite
Wireless Internet 
802.11 WiFi 

Which local repeater do you listen to the most?    Second Most?

Other 2-way communication equipment you use:   

GROL Number:     Computer Certifications:  

Have a current Dade County ARES/RACES ID card     EOC Unit Number:     GMRS Call:     

If you usually have an APRS tracker on in your vehicle, what is the call sign and SSID? (e.g. KD4BBM-1) 

AOL Instant Messenger (AIM) Screen Name: 

Personal Information:

Blood type:   Rh Factor:     Important medical issues:

Drivers License type (Class):     DL State:    DL Number: 

Date of Birth  Month     Day     Year            Weapons Permit:     

Other skills and/or training you have that would be valuable to the mission of ARPSC:

Additional information you would like to include in your record: 

Where do you expect to be during a hurricane? 

In a disaster, which Agency will do you consider to be your primary obligation?   Secondary?

Privacy Statement:   By submitting this form, you agree to share this information with the Miami-Dade County Amateur Radio Public Service Corps.  Do not share any information you wish to keep confidential.  

    I agree

rev 10/25/2005    Hit Counter