Resource Request: Medical and Health FIELD/HCF1 to Op Area
* = REQUIRED
RR MH (11/26/2019)

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 1. Incident Name:
* 
 2a. Request DATE/TIME:
* 
3. Requestor Name, Agency, Position, Phone / Email:
Requestor Name:* 
Agency:* 
Position:* 
Phone:* 
Email:* 
 2b. Request TRACKING NUMBER:
(Assigned by Requesting Entity)
* 
4a. Describe Mission/Tasks:
4b. Delivery/Reporting/Staging:
5. ORDER SHEETS / REQUEST TYPE: SUPPLIES EQUIPMENT PERSONNEL OTHER ONLY ONE TYPE PER REQUEST
6. ORDER
SUPPLY / EQUIPMENT / PERSONNEL REQUEST DETAILS

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#

 Priority2
(See Below)

DETAILED SPECIFIC ITEM DESCRIPTIONS:

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, etc.
Quantity Requested

New ITEM ROW is added after completing field

Expected
Equipment/
Staff Duration
of Use:

i.e. 14 hours,
2 days, etc.

1*
Detailed Specific Item Description
Vital characteristics, brand, specs, diagrams, and other info
(Type of Equipment, name, capabilities, output, capacity, Type of Supplies, name, size, capacity, etc.)
Product Class
(Ea, Box, Cs., Pack)		Items per Product Class
2
Detailed Specific Item Description
Vital characteristics, brand, specs, diagrams, and other info
(Type of Equipment, name, capabilities, output, capacity, Type of Supplies, name, size, capacity, etc.)
Product Class
(Ea, Box, Cs., Pack)		Items per Product Class
3
Detailed Specific Item Description
Vital characteristics, brand, specs, diagrams, and other info
(Type of Equipment, name, capabilities, output, capacity, Type of Supplies, name, size, capacity, etc.)
Product Class
(Ea, Box, Cs., Pack)		Items per Product Class
Suggested Source(s) of Supply; Suitable Substitute(s); Special Delivery Comment(s):
Deliver to/Report to POC (Name/Title/Location/Tel#/Email/Radio#)
Staging & Deployment Details
(Parking/staging location? Food/water provided? Housing Provided? Items personnel should bring? Etc.):
Additional Instructions

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 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)

   *  * 
1 HCF = Health Care Facility            2 Priority:   Emergent = <12 hours || Urgent = >12 hours || Sustainment