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 udohdoc@utah.gov. 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, bglarsen@utah.gov, 385-239-2967 or Brett Cross, bcross@utah.gov, 801-879-2912.
Sign in to Google to save your progress. Learn more
Name of Requestor: *
Agency of Requestor: *
Email of Requestor: *
Phone Number of Requestor: *
Resource Needed *
Required
Quantity (use "each" as unit of measure) *
Date Needed *
MM
/
DD
/
YYYY
Date of Demobilization *
MM
/
DD
/
YYYY
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? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of Utah. Report Abuse