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EMMA #:
{var EMMANo}
(Generated in WebEOC/CalEOC by Requesting Jurisdiction)
Incident Name: {var Incidentnam}
Request Date/Time:
{var RDateTime}
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REQUESTING JURISDICTION INFORMATION |
Requesting Jurisdiction Name:
{var ReqJuridiciton} |
24 Hour Phone Number:
{var phone24} |
EMMA Coordinator / PRIMARY Point of Contact Name:
{var coordinatePOC}
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Phone:
{var coordPhone}
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Alternate Phone:
{var coordaltphone} |
FAX: {var coordFax}
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E-Mail:
{var PocEamil}
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Alternate Point of Contact:
{var altPOC}
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Position / Title:
{var AltTile}
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Phone:
{var AltPOCphone}
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Alternate Phone:
{var altPOCAltPhone}
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FAX:
{var altPOCfax}
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Email :
{var altPOCEmail}
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How is the EMMA Resource being ordered?
{var HowOrderdval} |
If Post-Event MOU/MOA, what costs will be reimbursed?
(If different than reasonable costs outlined in Section 4.2 of EMMA Plan) |
{var rembCost1a}
{var rembCost2a}
{var rembCost3}
{var rembCost4a}
Other:{var RemCostOther} |
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Request Authorized By: (The following signature is an authorized official of the Requesting Jurisdiction. By signing, the Requesting Jurisdiction understands that this form does not constitute a contract with potential Providing Jurisdictions. A formal MOU must be established pre/post event with those jurisdiction requesting reimbursement for their services.)
Print Name:
{var pNAME} Signature:
{var pNAME2} Date:
{var pDATE}
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RESOURCE REQUESTED: |
(One Specific EOC Function or Position per request form.)
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Position Requested (Functional Title)
{var PosTitle} |
Quantity
{var quantity}
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Start Date/Time
{var Stime} |
End Date/Time
{var RDateTime3} |
Shift
{var shiftVal} |
Security Clearance?
{var securityval} |
Tasks to be performed:
{var Tasks}
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Attach Job Description
{var JObDecAttch}
{var jobDES}
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Any special skills / certifications / licenses required? {var SpecialSkills} |
If yes, please explain:
{var specExplain}
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EMMA resource needs to bring the following equipment (Laptop, vehicle, PPE, etc.):
{var fldII4} |
Must be Self-Contained?
{var shiftVal2} |
Requesting Jurisdiction will provide the following:
{var provide1a} {var provide2a} {var provide3a} {var provide4a} Other:
{var otherProvided}
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CHECK-IN LOCATION INFORMATION:
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Facility Name:
{var facilityName} |
Address:
{var facilityaddress} |
24 Hour Phone Number:
{var facility24hrphone}
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Directions:
Attach Map
{var directionMapAttached}
{var FaciltDirections} |
Point of Contact Name:
{var facilPOC}
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Cell Phone:
{avr facilCEll} |
Alt Phone:
{var faciltAltphone} |
Email:
{var faciltemail} |
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EXPECTED WORKING CONDITIONS |
Special health or environmental concerns in the assignment area:
{var concernsEnmviro} |
Hardship living / housing conditions
{var HarshipCondistions} |
Current Situation (Or attach most current Situation Report): Sit Rep attached:
{var SitReapattacha}
{var currentSit} |
{var Templateversion}
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