Resource Request: Medical and Health

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1. INCIDENT NAME

2a: Date

2b: Time

3. REQUESTOR
Name:

Agency:

Position:

Phone : Email:

2C. Requestor Tracking Number#
Facility code-3 digit number (assigned by requesting entity)

4. DESCRIBE MISSION

5. ORDER SHEETS - ATTACH ADDITIONAL

SUPPLIES

EQUIPMENT

PERSONNEL

OTHER

6. ORDER SUPPLY / EQUIPMENT / PERSONNEL REQUEST DETAILS

ITEM#	PRIORITY (SEE BELOW)³	DETAILED SPECIFIC ITEM DESCRIPTION: Supplies/Equipment (Rx: Drug Name, Dosage Form, UNIT OF USE PACK or Volume, Prod Info Sheet, In-House PO, photos, etc. Medical Supplies: Item name, Size, Brand, etc. General Supplies/Equipment: Food, Water, Generators) Personnel Type & Probable Duties (Required License, MD, RN, PharmD, ICU/OR Experience, Hospital/Clinical Experience, etc.) Other (Mobile Field Hospital; Ambulance Strike Team; Alternate Care Supply Cache; Facility-Tent, Trailer, Size, etc.)	Quantity Requested	EXPECTED EQUIPMENT / STAFF DURATION OF USE

R E V I E W	7. Requesting facility must confirm that these 3 requirements have been met prior to submission of request
	Is the resource(s) being requested exhausted or nearly exhausted?
	Facility is unable to obtain resources within a reasonable time frame (based upon priority level below) from vendors, contractors, MOU/MOA's or corporate office?
	Facility is unable to obtain resource from other non-traditional sources?
	8.COMMAND/MANAGEMENT REVIEW AND VERIFICATION (NAME, POSITION , AND SIGNATURE - SIGNATURE INDICATES VERIFICATION OF NEED AND APPROVAL) Name: Position: Signature:

¹ When EMS DOC activated MH-RR to be sent to Operations Section Coordinator ² HCF = Health Care Facility ³ Priority: (E)mergent <12 hours, (U)rgent >12 hours or (S)ustainment

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