4. Mission Phone Number 5. Mission Fax Number
1. From (Name of Country/Organization)
U.S. Department of State
3. Mission Working Hours
GENERAL INFORMATION (Please type or print the information requested in the spaces below)
Emergency management is a discipline that involves preparing for a disaster before it occurs, responding to it (i.e., emergency evacuation), and
assisting after the disaster has occurred. For prompt contact with embassies and consulates to ensure the Department of State can deliver information
and guidance in the event of an emergency, the Office of Foreign Missions is requesting after-hours emergency contact information of the senior
officials for all diplomatic and consular missions in the United States. All information is treated as sensitive and will be shared only with agencies
assigned to assist during a crisis situation. To that end, the Department would appreciate the following information:
2. Mission Physical Address
Provide the names, titles, after-hours phone numbers (including area codes), and e-mails of at least two Senior Officials (e.g., Ambassador, Consul
General, etc.) who can be reached in the event of an emergency.
6. First Contact
Name Title Home E-mail
Phone Number 1 (Specify Cell or Home) Phone Number 2 (Specify Cell or Home) Home Fax Number
7. Second Contact
Name Title Home E-mail
Phone Number 1 (Specify Cell or Home) Phone Number (Specify Cell or Home) Home Fax Number
8. Third Contact (Optional)
Name Title Home E-mail
Home Phone Number Cell Phone Number Home Fax Number
9. 24-Hour Duty Office
Duty Officer Name
Comments (If this is a rotational responsibility, please note and provide details.)
Duty Officer Title Duty Officer Phone Number
OMB APPROVAL NO. 1405-0105
EXPIRES: 05-31-2021
Cell Home Cell Home
Cell Home Cell Home
City State ZIP Code
Mission Function
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AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations
of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions Act of 1982
(22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to contact embassies and consulates and to ensure the U.S. Department of State can
deliver information and guidance in the event of an after-hours emergency/disaster.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in the Office of Foreign
Missions inability to assist after an emergency/disaster.
*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.
You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the
accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW, Washington,
DC 20008.
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