Resource Request Questions


Incident Name:

Priority

• When do you need this request fulfilled?
o 0-4 hours
o 4-8 hours
o 8-12 hours
o 12-36 hours
o Longer than 36 hours

Justification
• Does the county or local jurisdiction have the ability to contract for these resources?
o Yes
o No

• Have you exhausted all mutual aid options in the surrounding counties?
o Yes
o No

• Additional justification for the requested resource(s):
Justification Examples:
Local jurisdiction does not have this resource...
All existing resources have been contracted out...
Surrounding counties are also impacted...
No mutual aid is available...

Requesting Jurisdiction
• Requester Agency:
• Operational Area:

Requested Resources
• Resource Name:
• Quantity Requested (ea):
• Detailed Resource Description: (Vital characteristics, brand, specs, experience, size, etc.)
• Is an operator needed for this resource?

• Request Summary (Why is this resource needed and what will it do):

• Actions taken on this request so far (what have you done to obtain the resource on your own)?

Requester Information
• Requester First & Last Name:
• Requester Email:
• Requester Phone:
• Requester Title:

Delivery Information
• Recipient First & Last Name:
• Delivery Recipient Email:
• Delivery Recipient Phone:
• Delivery Recipient Title:
• Delivery Recipient Entity Name:
• Delivery Location:
• Delivery Notes:

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GOHSEP RESOURCE REQUEST FORM

 

 A.  RADO NAME:  B.  CALL SIGN:
 C.  DATE:  D.  TIME:
 GENERAL INFORMATION    RESOURCE DESCRIPTION & DELIVERY INSTRUCTIONS
INCIDENT #:
 1.  		 8. 
REQUESTER NAME:
 2. 
PARISH:
 3. 
DATE/TIME NEEDED:
 4. 
DURATION NEEDED:
 5. 
TRACKING # (DTG/PARISH):
 6. 
IS DELIVERY REQUIRED:  9.  YES      NO
RESOURCE TYPE  7.  REQUESTER POC DELIVERY INFORMATION
Air Support
Ambulance
Bottled Water
Bulk Water
Communications
Cots
Debris
DSNAP
Evacuation
Fire Protection
Fuel
( Fuel Form required)
Fuel Tanks
Generator
(Generator Form required)
Generator AND Fuel
(Generator & Fuel Form required)
Hazmat
Ice
Intel (Imagery)
Intel (Info)
Legal Support
Levee Support
Liasion
Mass Fatality
Mass Feeding
Medical Support
Mosquito Abate.
MRE (Meals)
PDA/IA
PDA/PA
Pets/Livestock
POD
Public Info
Roadway Inspect.
Sandbags
Search/Rescue
Security
Shelter Support
Tarps
Transportation
Utilities Restore
Waste Water Plnt.
Info Request
FIRST NAME:
 10. 
LAST NAME:
 11. 
AGENCY:
 12. 
PHONE:
 13. 
ALT. PHONE:
 14. 
E-MAIL:
 15. 
POC NAME:
 16. 
E-MAIL:
 17. 
PHONE:
 18. 
ALT. PHONE:
 19. 
NAME OF SITE:
 20. 
ADDRESS:
 21. 
Other
PARISH AUTHORIZATION
SIGNATURE:
 22.  		POSITION/TITLE:
 23. 
  GOHSEP Resource Request  v 1.07
 

Generator Form Supplement to GOHSEP Resource Request
Version 5/23/25

When requesting a generator, this form supplement must be completed and attached to your GOHSEP Resource Request Form.

 1.  POC Information:

 2.  Location/Address:

 3. Parish Tracking Number:

4. Delivery Time:

5. Do you have a backup generator: YES NO

6. Have power requirements been determined? YES NO

Provide Generator Size:
7. KW:

8. Voltage:

9. Phase:

Connection tie in:
10. Do you need cables? YES NO

11. How long should the cables be?

12. Do you have a transfer switch? YES NO

13. Has an assessment been done on the facility? YES NO

14. Do you have an electrician that can hook up the generator? YES NO

15. Do you need GOHSEP to provide fuel for the generator? YES NO

16. Are there any space restrictions that would impact placement and refuel operations? YES NO

17. (If #15 was Yes, provide additional information that identifies constraints and special equipment/materials needed.)
  

Fuel Form Supplement to GOHSEP Resource Request

Louisiana Department of Agriculture and Forestry Fuel Form Supplement to GOHSEP Resource Request

When requesting fuel, this form supplement must be completed and attached to your GOHSEP Resource Request Form.

1. Date:

2. Name of Incident:

3. Incident Number:

4. What is the Fueling mission?

5. What type of Equipment needs to be refueled (Vehicles, Generators, Bulk Fuel Tank, Other)?    

6. What Fuel Type is needed (Gas, Diesel, Av Gas, Jet-A, Other)?

7. What is the Quantity of Fuel being requested?

8. What is the Priority of Fueling Mission (Urgent, Same Day, Next Day, Other)?

9. Are there any Special Conditions for the Fueling Mission (Length of hose required, special fitting or connections on tank)?
 

10. Are there any Time Restrictions for making the Fuel Delivery ?   YES NO

11. What is the best time for receiving?

List two points of contact with working Phone Numbers:
12. Contact Name:

13. Contact Phone:

14. Alternate Name:

15. Alternate Phone:

For Bulk Fuel Deliveries to an Existing Bulk Fuel Storage Tank
16. What is the Capacity of the Tank?

17. What is the Existing Inventory?

18. Is the Tank (Aboveground or Underground)?

19. Will there be a Site Representative present to meet with the driver prior to unloading to verify that the Tank will hold the quantity of product that was ordered ? YES NO

For Bulk Fuel Deliveries where Vendor must Provide the Bulk Fuel Storage Tank
20. What is the Size of the Tank being requested in gallons?

21. What Power Source is available for the pump (AC or DC)?

22. Is a Forklift onsite to offload the Tank ? YES NO

Required Fuel Billing Information
23. Party responsible for this fuel bill:

24. Billing address:

25. Billing point of Contact:

26. Billing phone Number:

27. Billing Authorized User:

28. Agency Number:

This form was modeled from AHS-20-39 (R. 1/14)
                GOHSEP Resource Request  v 1.07