Fillable Local American Citizen Skills/Resources Survey Form DS-5506

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Local American Citizen Skills/Resources Survey Form DS-5506

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The Local American Citizen Skills/Resources Survey Form DS-5506 form is 3 pages long and contains:

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  • 44 check-boxes
  • 37 other fields

Country of origin: US
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The US Department of State (DOS) or the State Department, is the government official division that advises the President and performs international relations. Equivalent to the outside service of different nations, it was built up in 1789 as the country's first official department.

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U.S. citizens abroad may possess critical skills and resources invaluable for helping other U.S. citizens in a time of crisis.
The Consular Section of the U.S. Embassy/Consulate would appreciate your assistance in identifying these skills and
resources. Please provide relevant details about yourself and return this survey to us by e-mail, fax, or in person to the
American Citizens Services unit of the Consular section of the nearest U.S. embassy or consulate. Family members may
submit separate forms or you may include their information on this form with their consent. We will keep your responses
confidential. Please see the Privacy Act Statement on page 3.
U. S. Department of State
DS-5506
02-2016
Page 1 of 3
EMBASSIES/CONSULATES OF THE UNITED STATES OF AMERICA
OMB NO. 1405-0188
EXPIRES: 05/31/2019
Estimated Burden - 15 minutes
LOCAL UNITED STATES CITIZEN SKILLS/RESOURCES SURVEY
Full Name
OCCUPATION(S) AND OTHER SKILLS
Please place a check in each box that describes the skills you possess.
Law Enforcement
Emergency Response
Search and Rescue
Social Services
Foreign Language
Military
Medical
Other
Engineering Operation
Heavy Machinery
Construction/Extraction
Electrical
Carpentry
Food Service
Please provide additional details about the skills marked above.
Date (mm-dd-yyyy)
(Last, First, MI)
(oral / written)
(specify if other)
Telephone Number(s)
E-mail Address
Address
City
Country
Additional Resources or Information
Level 1 - Communication is limited to a few words.
Level 2 - Comprehension of very simple written material.
Level 3 - Can satisfy social demands and limited work requirements.
Level 4 - Functioning in a social and professional setting.
Level 5 - Equivalent to a native speaker.
Translator (T) - convert one language into another through writing.
Interpreter (I) - convert one language into another through oral communication.
LANGUAGE SKILL
1. In the first box, please indicate your level of proficiency as a "Translator." In the second box, please indicate
your level of proficiency as an "Interpreter."
Bengali
Hindi
Russian
German
T I
Urdu
Arabic
(please specify)
Tagalog
Swahili
Yes No
(If yes, please specify)
Other Languages
Farsi/Dari
RESOURCES
In the event of a crisis, I may be able to provide:
Page 2 of 3
TRANSPORTATION
TYPE
PASSENGER CAPACITY
SHELTER TYPE LOCATION CAPACITY
FOOD SERVICE LOCATION CAPACITY
DS-5506
Asian-based Languages
(please specify)
Latin-based Languages
(please specify)
Page 3 of 3
RESIDENCY STATUS
Please place a check in each box that applies.
I am permanently a resident in
I am temporarily a resident in until
(mm-dd-yyyy)
DateCountry
I travel to and from several times a year.
Country
Signature, or Typed Name if Submitted by Email
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §
4802(b), 31 U.S.C. § 1342, 22 CFR § 71.1 and 22 CFR § 71.6.
PURPOSE: The principal purpose of gathering this information is to identify U.S. citizens residing
in a particular country who may possess critical skills and resources invaluable for helping other
Americans in a time of crisis. Absent your prior written consent, no information on this form may be
disclosed to any persons or agency unless such a disclosure would be permitted by the Privacy
Act, 5 USC552a (b) ("Conditions of disclosure").
ROUTINE USES: The information on this form may be shared with federal, state, and local
government agencies; members of Congress; officials of foreign governments; U.S. and foreign
courts; U.S. and foreign nongovernmental organizations, including disaster or emergency relief
organizations such as the International Red Cross, Red Crescent and others. This information
collection is covered by the System of Records Notice.
Responding to this survey is purely voluntary.
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: CA/OCS/PMO, U.S. Department of State,
SA-17, 10th Floor, Washington, DC 20522-1707.
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Country
Date
(mm-dd-yyyy)
.
.
DS-5506
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Local American Citizen SkillsResources Survey Form DS-5506

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Completed 14 May 2019

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