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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EMMA FORM 1A
EMMA RESOURCE REQUEST
(REV. 9/2018)   Form Info

 

EMMA #:
  (Generated in WebEOC/CalEOC by Requesting Jurisdiction)

Incident Name:

Request Date/Time:

REQUESTING JURISDICTION INFORMATION
Requesting Jurisdiction Name:   
24 Hour Phone Number:
EMMA Coordinator / PRIMARY Point of Contact Name:
Phone: 
 
Alternate Phone:  FAX 
E-Mail:
Alternate Point of Contact:
Position / Title: Phone:
Alternate Phone:
FAX: Email :  
How is the EMMA Resource being ordered?       Mutual Aid                 Post-Event MOU/MOA     

If Post-Event MOU/MOA, what costs will be reimbursed?

(If different than reasonable costs outlined in Section 4.2 of EMMA Plan)

Salary Overtime Benefits Travel Lodging

Other;

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:  :Title:      Date:

RESOURCE REQUESTED:
(One Specific EOC Function or Position per request form.)
Position Requested (Functional Title):
Quantity
Start Date/Time

End Date/Time

Shift
Day Night

Security Clearance?
Yes NO
Tasks to be performed:

 Attach Job Description

Any special skills / certifications / licenses required? Yes NO

If yes, please explain:

EMMA resource needs to bring the following equipment (Laptop, vehicle, PPE, etc.):

Must be Self-Contained?

Yes No

Requesting Jurisdiction will provide the following:
Lodging     Meals     Computer/Laptop     Other:
CHECK-IN LOCATION INFORMATION:
Facility Name:
 
Address:
 
24 Hour Phone Number:
 

Directions:                   Attach Map
Point of Contact Name:

Cell Phone:
Alt Phone:
Email:
EXPECTED WORKING CONDITIONS
Special health or environmental concerns in the assignment area:
Hardship living / housing conditions (Lack of power or potable water, no wraparound services, unusual accomodations, etc.):
 

Current Situation (Or attach most current Situation Report):
   Attach Sit Rep

                                       EMMA FORM 1A   v1.0