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:

Back to links

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

 

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

Incident Name:

Request Date/Time:

REQUESTING JURISDICTION INFORMATION
County/Operational Area:
Requesting Jurisdiction Name:   
24 Hour Phone Number:
OA EMMA Coordinator / PRIMARY Point of Contact Name:
Phone: 
 
Alternate Phone:  FAX 
E-Mail:
Providing Jurisdiction Point of Contact: Position / Title:
Phone: Alternate Phone:
FAX:
Email :

Providing Jurisdiction Authorization: (The following signature of the Providing Jurisdiction indicates a good-faith effort to ensure the EMMA resource(s) listed on this form is qualified to fulfill the request and is available for deployment. It is understood that this form does not constitute a contract with the Requesting Jurisdiction. Mutual aid extended under the EMMA Plan shall be without reimbursement unless otherwise established in a separate pre/post-event agreement between the Requesting and Providing Jurisdictions.)

Print Name and Title:          Signature:

 
CONTINUED - POTENTIAL EMMA RESOURCE INFORMATION (MAY LIST UP TO 4 PEOPLE PER POSITION):
#1       (For Requesting Jurisdiction only: Check this box to select EMMA resource for assignment.)
Name: Title: Cell Phone:
Email: Available for time as specified on Form A?     Yes NO
Able to perform tasks described in Form A?    Yes     NO Security Clearance (If applicable)?    Yes     NO
Has required equipment per Form A?              Yes     NO
(Personal Equipment Disclaimer HERE)
Is aware of expected working conditions?     Yes     NO
Self-Contained?      Yes     NO Comments/Other:
Experience / EOC Position Credentials:
Special Skills / Licenses / Certifications:
Originating City/County: Estimated Travel Time::
Emergency Contact Name:

Relationship::
Cell Phone:
Email:
Special Pay/Compensation Considerations:
 
#2       (For Requesting Jurisdiction only: Check this box to select EMMA resource for assignment.)
Name: Title: Cell Phone:
Email: Available for time as specified on Form A?     Yes NO
Able to perform tasks described in Form A?    Yes     NO Security Clearance (If applicable)?    Yes     NO
Has required equipment per Form A?              Yes     NO
(Personal Equipment Disclaimer HERE)
Is aware of expected working conditions?     Yes     NO
Self-Contained?      Yes     NO Comments/Other:
Experience / EOC Position Credentials:
Special Skills / Licenses / Certifications:
Originating City/County: Estimated Travel Time::
Emergency Contact Name:

Relationship::
Cell Phone:
Email:
Special Pay/Compensation Considerations:
 
 
#3       (For Requesting Jurisdiction only: Check this box to select EMMA resource for assignment.)
Name: Title: Cell Phone:
Email: Available for time as specified on Form A?     Yes NO
Able to perform tasks described in Form A?    Yes     NO Security Clearance (If applicable)?    Yes     NO
Has required equipment per Form A?              Yes     NO
(Personal Equipment Disclaimer HERE)
Is aware of expected working conditions?     Yes     NO
Self-Contained?      Yes     NO Comments/Other:
Experience / EOC Position Credentials:
Special Skills / Licenses / Certifications:
Originating City/County: Estimated Travel Time::
Emergency Contact Name:

Relationship::
Cell Phone:
Email:
Special Pay/Compensation Considerations:
 
#4       (For Requesting Jurisdiction only: Check this box to select EMMA resource for assignment.)
Name: Title: Cell Phone:
Email: Available for time as specified on Form A?     Yes NO
Able to perform tasks described in Form A?    Yes     NO Security Clearance (If applicable)?    Yes     NO
Has required equipment per Form A?              Yes     NO
(Personal Equipment Disclaimer HERE)
Is aware of expected working conditions?     Yes     NO
Self-Contained?      Yes     NO Comments/Other:
Experience / EOC Position Credentials:
Special Skills / Licenses / Certifications:
Originating City/County: Estimated Travel Time::
Emergency Contact Name:

Relationship::
Cell Phone:
Email:
Special Pay/Compensation Considerations:
 
                                       EMMA FORM B   v1.0