Resource Request: Medical and Health
{var IsExercise} |
FIELD/HCF2 to Op Area
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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}
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2C. Requestor Tracking Number#
Facility code-3 digit number (assigned by requesting entity)
{var TrackingNum} |
4. DESCRIBE MISSION
{var Mission}
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5. ORDER SHEETS - ATTACH ADDITIONAL |
{var Supply} SUPPLIES
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{var Equipment}
EQUIPMENT
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{var Personnel}
PERSONNEL
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{var Other}
OTHER
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6. ORDER SUPPLY / EQUIPMENT / PERSONNEL REQUEST DETAILS |
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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.)
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Quantity Requested
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EXPECTED EQUIPMENT /
STAFF DURATION
OF USE
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{var item1} |
{var pri1}
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{var detail1}
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{var Quanity1} |
{var duration1} |
{var item2} |
{var pri2} |
{var detail2}
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{var Quanity2} |
{var duration2} |
{var item3} |
{var pri3} |
{var detail3}
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{var Quanity3} |
{var duration3} |
{var item4} |
{var pri4} |
{var detail4}
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{var Quanity4} |
{var duration4} |
{var item5} |
{var pri5} |
{var detail5}
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{var Quanity5} |
{var duration5} |
{var item6} |
{var pri6} |
{var detail6}
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{var Quanity6} |
{var duration6} |
{var item7} |
{var pri7} |
{var detail7}
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{var Quanity7} |
{var duration7} |
{var item8} |
{var pri8} |
{var detail8}
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{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?
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{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?
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{var C7} Facility is unable to obtain resource from other non-traditional sources?
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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
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Express Sending Station: {var MsgSender} |
Version 0.3.9.5
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