Health & Medical Logistics Request Form
This form is to be used to request assets from the Utah Department of Health for a preplanned event. If this is an emergency request please call 1-866-364-8824 and email
. Please complete this form and a member of our logistics team will contact you as soon as possible. If you have questions please contact Bryan Larsen,
, 385-239-2967 or Brett Cross,
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Name of Requestor:
Agency of Requestor:
Email of Requestor:
Phone Number of Requestor:
Mobile Field Hospital (BluMed)
Mass Casualty Trailer
Response Personnel Support Trailer
Pediatric Response Trailer
Mass Fatality Response Equipment
Medical Task Force
800 mhz Radio Kit
VHF Radio Kit
Blood Stop Training Kit
Rapid Deploy Shelters
PPE N95 Masks
PPE Face Shields
Drive Thru Shelter 30x50
Quantity (use "each" as unit of measure)
Date of Demobilization
Event the Resources are Supporting:
Description of Event and how the Resource will be used:
Does your agency have trained personnel to set up/take down/operate the equipment requested?
We have some, but need an SME to assist.
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This form was created inside of State of Utah.