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

 

EMMA #: {var EMMANo}
  (Generated in WebEOC/CalEOC by Requesting Jurisdiction)

Incident Name: {var Incidentnam}

Request Date/Time: {var RDateTime}

REQUESTING JURISDICTION INFORMATION
Requesting Jurisdiction Name:  {var ReqJuridiciton}  
24 Hour Phone Number: {var phone24}
EMMA Coordinator / PRIMARY Point of Contact Name: {var coordinatePOC}
Phone:  {var coordPhone}
Alternate Phone:  {var coordaltphone} FAX:  {var coordFax}
E-Mail: {var PocEamil}
Alternate Point of Contact: {var altPOC}
Position / Title: {var AltTile} Phone: {var AltPOCphone}
Alternate Phone: {var altPOCAltPhone}
FAX: {var altPOCfax} Email : {var altPOCEmail}  
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}

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}

RESOURCE REQUESTED:
(One Specific EOC Function or Position per request form.)

Position Requested (Functional Title)
{var PosTitle}

Quantity
{var quantity}

Start Date/Time
{var Stime}

End Date/Time
{var RDateTime3}

Shift
{var shiftVal}

Security Clearance?
{var securityval}

Tasks to be performed:
{var Tasks}

 Attach Job Description   {var JObDecAttch}
{var jobDES}

Any special skills / certifications / licenses required?  {var SpecialSkills}

If yes, please explain:
{var specExplain}

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}

CHECK-IN LOCATION INFORMATION:

Facility Name:
{var facilityName}

Address:
{var facilityaddress}

24 Hour Phone Number:

  {var facility24hrphone}

Directions:                  Attach Map {var directionMapAttached}

{var FaciltDirections}

Point of Contact Name:
{var facilPOC}
Cell Phone:
{avr facilCEll}
Alt Phone:
{var faciltAltphone}
Email:
{var faciltemail}
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}