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 Resource Request Medical and Health: FIELD/HCF2 To Op Area
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1. Incident Name:

2a. DATE: 2b. TIME:
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3. Requestor Name, Agency, Position, Address, Phone / Email:

2c. Requestor Tracking Number:
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Facility code+3 digit number (Assigned by requesting entity)
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4. Describe Mission/Tasks:
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5. ORDER SHEET(S) - ATTACH ADDITIONAL IF NEEDEDSUPPLIESPERSONNELEQUIPMENT
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6. ORDER MEDICAL & HEALTH REQUEST DETAILS
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Item#Priority3 Detailed Specific Item Description: Vital characteristics, brand, specs, diagrams, and other info. (Rx: Drug Name, Dosage Form, UNIT OF USE PACKAGE or Volume, etc.) (Attach product information pages, photos, In-House purchase order documentation)QtyExpected Duration of Use
(does not apply to supplies)
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7. Requesting facility must confirm that these 3 requirements have been met prior to submission of request
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Is the resource(s) being requested exhausted or nearly exhausted?
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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?
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Facility is unable to obtain resource from other non-traditional sources?
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8. COMMAND/MANAGEMENT REVIEW AND VERIFICATION
(NAME, POSITION , AND SIGNATURE - SIGNATURE INDICATES VERIFICATION OF NEED AND APPROVAL)
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