Form: LA Resource Request.html,LA Resource Request Viewer.html
To:
Subject: LA Resource Request: # ,
Msg:
Resource Request Medical and Health: FIELD/HCF to Op Area
1. INCIDENT NAME:
2a: Date:
2b: Time:
2C. Requestor Tracking Number#
3. REQUESTOR
Name:
Agency:
Position:
Phone : Email:
4, DESCRIBE MISSION
5. ORDER SHEETS - ATTACH ADDITIONAL
SUPPLIES
EQUIPMENT
PERSONNEL
OTHER
6. ORDERÂ SUPPLY / EQUIPMENT / PERSONNEL REQUEST DETAILS
Item# Priority ITEM DESCRIPTION Quantity Requested EXPECTED EQUIPMENT/STAFF DURATION
7. Requesting facility must confirm that these 3 requirements have been met prior to submission of request
Is the resource(s) being requested exhausted or nearly exhausted?
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?
Facility is unable to obtain resource from other non-traditional sources?
8.COMMAND/MANAGEMENT REVIEW AND VERIFICATION
(NAME, POSITION , AND SIGNATURE - SIGNATURE INDICATES VERIFICATION OF NEED AND APPROVAL)
Name:
Position:
Signature:
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Express Sending Station:
Senders Express Version:
Senders Template Version: