Disaster Receipt Form – Form 6409-B
                                                                                                                             Form 6409B Instructions

DR# (if applicable):     DR Name:        Date:        Requisition # :  

 Requestor Name :
 Signature:
 Title :
 Phone:
Delivery Information
 Site POC Name :   Phone:    Email:  
Address:
 City:    State:  Zip:     
Description of product(s) and/or service(s)
Stock No.
Quantity
Unit of measure
(EA/PK/CS/BX)
Total QTY (each)
Description
 Date needed
Note:
Acknowledgement by person receiving product(s) and/or service(s).
      I hereby certify that I have received all product(s) and/or service(s) listed above.
 If all product(s) and/or service(s) have not been received, provide explanation in the space below.
Discrepancies:
 Received by Print Name:
 Received by Signature:
 Date:                                  Time of arrival:  
 Group:

            

DCS JT DMWT Disaster Requisition (F6409) V.2.0 2015.02.13                                                                                        ARC 6509-B v. 0.12

 

ARC 6409B

The ARC Requisition 6409 and the ARC Disaster Receipt 6409-B are designed to work together.

Station#1 will fill out the Requisition 6409, and send to Station #2 to fill the order.

When station #2 receives and views the 6409 request, there is a button on the viewer form to "Save Requisition 6409 data for Receipt form 6409B"

Then station #2 loads the 6409B form Data. They can load the data from the original order by clicking the button "Load Requisition form 6409 data";

If needed the order can be modified as the order is filled-
example if 10 cases of water are not available and only 5 cases can be shipped, they can modify the order to reflect what they are sending.

The 6409B order is then send to Station #1. When the order is delivered, they complete the section of the 6409B
"Acknowledgement by person receiving product(s) and/or service(s)."
and send it back.
- - - - - - - -

The Disaster Receipt Form (6409-B) is to acknowledge receipt of product(s) and or service(s) requested on the Disaster Requisition Form (6409) by Group/Activity on the DRO.

DR #: Enter the DR # and year (If applicable).
DR Name: Enter the DR Name.
Requisition #: Requisition number from the corresponding F6409
Site POC: Enter the POC name
POC Phone: Enter POC’s Phone Number POC E-mail_ Enter POC’s E-mail

Description of product(s) and/or service(s)
Stock No.: Enter the Stock No. for the Item if known
Quantity: Enter the # of Units of Measure if known
Unit of Measure: Enter the Unit of Measure (EA-Each; PK-Pack;
CS-Case; BX-Box) if known

Total Qty (Each): Enter the number Quantity x Unit of measure = Total Each. If unit of measure is not known enter total number of product needed.
Description: Enter the description of the product(s) or service(s) Need by: Enter the date and time for when the product(s) or
service(s) are needed

Acknowledgement by person receiving item
Checkbox: Certifies receipt of items
Discrepancies: List any discrepancies here.
Received by (Printed name): Enter the name of the recipient Received by (Signature): Enter the signature of the recipient Date: Enter date in mm-dd-yy format
Time of Arrival: Enter arrival time
Group: Enter the Recipient’s Group/Activity/Position

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