GOHSEP Resource Request

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:

GOHSEP RESOURCE REQUEST FORM

A. RADO NAME: {var RADO}	B. CALL SIGN: {var RADOCall}
C. DATE: {var RDateTime2}	D. TIME: {var RDateTime3}

GENERAL INFORMATION		RESOURCE DESCRIPTION & DELIVERY INSTRUCTIONS
INCIDENT #: 1. {var Incidentnum}		8. {var DESC-DELIVERY}
REQUESTER NAME: 2. {var RequesterName}
PARISH: 3. {var PARISH}
DATE/TIME NEEDED: 4. {var RDateTime}
DURATION NEEDED: 5. {var Duration}
TRACKING # (DTG/PARISH): 6. {var TrackongNum}		IS DELIVERY REQUIRED: 9. {var DeliveryNeeded}

RESOURCE TYPE 7.

REQUESTER POC

DELIVERY INFORMATION

FIRST NAME:
10. {var thename2}

LAST NAME:
11. {var LastName}

AGENCY:
12. {var Agency}

PHONE:
13. {var ReqPhone}

ALT. PHONE:
14. {var ReqPhone2}

E-MAIL:
15. {var ReqPhone3}

POC NAME:
16. {var POCname}

E-MAIL:
17. {var POCemail}

PHONE:
18. {var POCphone}

ALT. PHONE:
19. {var POCaltphone}

NAME OF SITE:
20. {var POCSite}

21. ADDRESS:
{var DESC-DELIVERY2}

{var rESOURCEtYPE}

PARISH AUTHORIZATION

SIGNATURE:
22. {var Signsture}

POSITION/TITLE:
23. {var Position}

GOHSEP Resource Request v 1.06

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: {var Gen1}

2. Location/Address: {var Gen2}

3. Parish Tracking Number: {var Gen3}

4. Delivery Time: {var Gen4}

5. Do you have a backup generator: {var Gen5}

6. Have power requirements been determined? {var Gen6}

Provide Generator Size:
7. KW: {var Gen7 }

8. Voltage: {var Gen8}

9. Phase: {var Gen9}

Connection tie in:
10. Do you need cables? {var Gen10}

11. How long should the cables be? {var Gen11}

12. Do you have a transfer switch? {var Gen12}

13. Has an assessment been done on the facility? {var Gen13}

14. Do you have an electrician that can hook up the generator? {var Gen14}

15. Do you need GOHSEP to provide fuel for the generator? {var Gen15}

16. Are there any space restrictions that would impact placement and refuel operations? {var Gen16}

17. (If #15 was Yes, provide additional information that identifies constraints and special equipment/materials needed.)
{var Gen17}

Fuel Form Supplement to GOHSEP Resource Request Form

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: {var Fuel1}

2. Name of Incident: {var Fuel2}

3. Incident Number: {var Fuel3}

4. What is the Fueling mission? {var Fuel4}

5. What type of Equipment needs to be refueled (Vehicles, Generators, Bulk Fuel Tank, Other): {var Fuel5}

6. What Fuel Type is needed (Gas, Diesel, Av Gas, Jet-A, Other)? {var Fuel6}

7. What is the Quantity of Fuel being requested? {var Fuel7}

8. What is the Priority of Fueling Mission (Urgent, Same Day, Next Day, Other)? {var Fuel8}

9. Are there any Special Conditions for the Fueling Mission (Length of hose required, special fitting or connections on tank)?
{var Fuel9}

10. Are there any Time Restrictions for making the Fuel Delivery? {var Fuel10}

11. What is the best time for receiving? {var Fuel11}

List two points of contact with working Phone Numbers:
12. Contact Name: {var Fuel12}

13. Contact Phone: {var Fuel13}

14. Alternate Name: {var Fuel14}

15. Alternate Phone: {var Fuel15}

For Bulk Fuel Deliveries to an Existing Bulk Fuel Storage Tank
16. What is the Capacity of the Tank? {var Fuel16}

17. What is the Existing Inventory? {var Fuel17}

18. Is the Tank (Aboveground or Underground)? {var Fuel18}

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 ? {var Fuel19}

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? {var Fuel20}

21. What Power Source is available for the pump (AC or DC)? {var Fuel21}

22. Is a Forklift onsite to offload the Tank? {var Fuel22}

Required Fuel Billing Information
23. Party responsible for this fuel bill: {var Fuel23}

24. Billing address: {var Fuel24}

25. Billing point of Contact: {var Fuel25}

26. Billing phone Number: {var Fuel26}

27. Billing Authorized User: {var Fuel27}

28. Agency Number: {var Fuel28}

This form was modeled from AHS-20-39 (R. 1/14)

GOHSEP Resource Request v 1.06