Resource Request: Medical and Health  

{var IsExercise}

   FIELD/HCF2 to Op Area
   

RR MH (05/24/2011) 

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1. INCIDENT NAME
 {var Incident}
2a: Date
{var TheDate}
2b: Time
{var Time1}
3. REQUESTOR
  Name: {var REQName}

  Agency: {var REQAgency}

  Position: {var REQPosition}

  Phone : {var REQPhone}     Email: {var REQemail}

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

 {var TrackingNum}
4. DESCRIBE MISSION
{var Mission}
5. ORDER SHEETS - ATTACH ADDITIONAL {var Supply} SUPPLIES {var Equipment} EQUIPMENT {var Personnel} PERSONNEL {var Other} 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

 

{var item1}
{var pri1}
{var detail1}  
{var Quanity1} {var duration1}
{var item2}
{var pri2}
{var detail2}  
{var Quanity2} {var duration2}
{var item3}
{var pri3}
{var detail3}  
{var Quanity3} {var duration3}
{var item4}
{var pri4}
{var detail4}  
{var Quanity4} {var duration4}
{var item5}
{var pri5}
{var detail5}  
{var Quanity5} {var duration5}
{var item6}
{var pri6}
{var detail6}  
{var Quanity6} {var duration6}
{var item7}
{var pri7}
{var detail7}  
{var Quanity7} {var duration7}
{var item8}
{var pri8}
{var detail8}  
{var Quanity8} {var duration8}

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7. Requesting facility must confirm that these 3 requirements have been met prior to submission of request
{var A7} Is the resource(s) being requested exhausted or nearly exhausted?

{var B7} 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?

{var C7} 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: {var CMDName}

Position: {var CMDPosition}

Signature: {var CMDSignature}

     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

  Express Sending Station:  {var MsgSender}     
Version 0.3.9.5