Facility Staffing Request Form
PLEASE NOTE: All medical personnel must be vetted and credentials validated by Alameda County.
Organizations with multiple locations should make every attempt to combine requests through their emergency manager in one submission.
Please regularly monitor and anticipate your staffing needs. When requesting staffing, attempt to give at least a five-day lead time as personnel may be coming from a distance and lodging arrangements may also need to be made. Have your just-in-time training developed and ready for when your requested personnel report to your facility or location.
When filling out this form please consider what tasks you are expecting from requested personnel (type of patient care including procedures, medication administration, management of specific devices, clinical assessments, etc.).
Name of Organization/Facility
Type of Facility
Long Term Care Facility
Urgent Care Clinic
Skilled Nursing Facility
Medical Transport Provider
If other please specify facility type:
Who should be contacted if more details are needed and/or to confirm your request?
What is the phone number to contact the above person?
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