HomeMy WebLinkAboutmhoac-rr-blank-no-ast_______
RR MH (11AUG11)
2b. TIME:
Demob Expected:
Operational Area:
Outside of Region:
Page 1 of
Resource Request: Medical and Health Op Area (MHOAC) to Region/State
6c. OTHER:6a. SUPPLIES/EQUIPMENT
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7a. OA/MHOAC must confirm that the verification questions in the PH&M EOM have
been reviewed and answered.
2c. Requestor Tracking #:
(Assigned by Requesting Entity)
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8. MHOAC/OA EOC Review: (NAME, POSITION , AND SIGNATURE) [SIGNING INDICATES: 1) THE NEED HAS BEEN
VERIFIED; 2) RESOURCES ARE NOT AVAILABLE AT THIS LEVEL; and, 3) THE REQUEST IS COMPLETE)
NAME: POSITION: SIGNATURE:
5. ORDER SHEETS - USE ATTACHED
This request meets the submission criteria as stated in the PH&M EOM.
6b. PERSONNEL
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NOTE: To be completed by the Level/Entity that fills the request (OA EOC, Region, State).
4a. Describe Mission/Tasks: 4b. Delivery/Reporting/Staging Information:
The creation of this request was in consulation with the RDMHC Program.
7b. MHOAC/OA EOC Contact Information: (Tele #, E-Mail, FAX, etc.)
12. Resource Tracking:
Entered into Resource Tracking System/RIMS
Demob Completed (if known):
10. Additional Order Fullfillment Information: 11. Likely Supplier Name/Phone/Email:
1. Incident Name:2a. DATE:
3. Requestor Name, Agency, Position, Phone / Email:
16. Finance Section Signature & Date/Time: (Name, Position & Verification)
14. ORDER FILLED AT (check box)
9. Describing the actions taken on this request so far.
13. Notes:
OA within Mutual Aid Region:
15. Reply/Comments from Finance:
2 a. Date:
b. Time:
3. Requestor Name & POC Info:
4 a. Describe Mission/Tasks:
b. Delivery/Reporting/ Staging
Info:
5. Order Sheets:
Item #:
Priority:
Detailed Description:
Quantity Requested:
Expected duration of use:
Suggested Source(s)
Suitable Substitute(s)
Special Delivery Comments:
7 a. Confirm Requirements:
b. MHOAC/OA EOC Contact Info
8. MHOAC/OA EOC Review
9. Actions Taken:
10. through 17.
Resource Request Medical and Health (RRMH) Completion Instructions
11AUG11
Note: Within any large cell you can move to a new line within the cell by holding down the "Alt" Key and
pressing the "Enter" Key once for each new line needed.
1. Incident Name:Name assigned by Incident Commander: Be as general as possible, i.e.; March 2011 EQ or
IED at the Convention Center.
Provide Name, Title, Location, Telephone #, E-mail, Radio Call Sign/#, and Deployment
information to who will be receiving the requested items and where they should be delivered
or who will receive or meet the personnel, where they should arrive or stage, and what they
should bring or have available to them.
Use mm/dd/yyyy format
c. Requestor Tracking Number:
OA/MHOAC must confirm and verify that the request is in compliance with the provisions of
the California Public Health & Medical Emergency Operations Manual and has been
coordinated with the Regional Disaster Medical Health Coordination (RDMHC) Program.
Military Time is preferred, i.e. 1900 = 7:00pm. If unable to use Military Time indicate am or
pm.
This is a requestor generated number. This could be the original requesing Field Entity/Health
Care Facility's Tracking Number. Or, the Operational Area EOC/ MHOAC could include a OA
Tracking Number in this box for a reference number for their purposes. The Region, REOC,
SOC, could also include a Tracking Number here for their tracking purposes.
List the complete contact information of the requestor/creator of RRMH
Give a brief description of reason for request or duties to be performed.
Each NEW line item is numbered.
Check each box that applies to your order.
6. Order - 6a. Supply/Equipment; 6b. Personnel; and/or, 6c. Other Sheets Details:
Provide information regarding actions that have been taken to fill the request within the OA or
through existing MOUs/MOAs.
To be completed by level/entity filling the request.
Specifically describe the requested item by using brand, sizes, model #, dose, form (tabs vs
caps vs suspension), strength, quantities,etc. Example: 3M N-95 Mask, Model #1234 size
Medium or Penicillin 500mg tablets - 100 tablet/bottle, or Normal Saline1000ml IV fluid. RN
w/ICU Experience, PharmD, MD w/OR Experience. Ambulance Strike Team (AST);
Generator - Gas, 6000 KW; Drinking Water - 16oz bottles, etc.
Quantity wanted based upon each, this is to simplify the ordering process. Example: Penicillin
500mg Tabs - 100 Tabs/bottle - Quantity Requested 50 = hospital will receive 5000 tablets; N-
95 3M 1860 1 Case = 120/case; IV fluid 1 Case = 12 Bags; AST 1 = 5 Ambulances with 1
Strike Team Leader; Water 1 Case = 24 bottles.
This only applies to equipment and personnel. Supplies will normally be considered
expendible and will not be returned.
(E)mergent <12 hours, (U)rgent >12 hours or (S)ustainment. If completing form electronically
there is a drop down menu.
Include Telephone, Blackberry, FAX, E-mail, Points of Contact for reviewer.
Provide any known or potential sources for the items requested; any suitable substitutes that
might be acceptable; or, any comments or special delivery instructions, location or Point of
Contact.
Authorized MHOAC/OA EOC staff review and verification. Printed name, position, and
signature are required.
ORDER SHEET
PAGE _____OF _____
Detailed Specific Item Description:
Vital characteristics, brand, specs, diagrams, and other info
(Type of Equipment, name, capabilities, output, capacity, Type of Supplies, name, size, capacity,
etc. )Approved Filled Back-
Ordered
11AUG11
COST
Suggested Source(s) of Supply; Suitable Substitute(s); Special Delivery Comment(s):
QuantityProduct Class
(Ea, Box, Cs,
Pack)
Items per
Product Class
Quantity 2
Requested
Expected
Duration of Use:
Estimated Time
of Arrival
(Date & Time)
3 PRIORITY: (E)mergent <12 hour (RIMS:FLASH/HIGH), (U)rgent >12 hour (RIMS: MEDIUM) or (S)ustainment (RIMS: LOW)
2 QUANTITY: Number of individual pieces of equipment or boxes, cases, or packages of supplies needed .
6a. ORDER GENERAL: SUPPLY/EQUIPMENT REQUEST DETAILS 17. Logistics Section: Fulfillment
NOTE: To be completed by the Level/Entity that fills the request (OA EOC, Region, State).
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Deliver to/Report to POC (Name/Title/Location/Tel#/Email/Radio#)
Tracking #
ORDER SHEET
PAGE _____OF _____
PAID NON-PAID
Personnel Type & Probable Duties
Indicate required license types (see list below) RN, MD,
EMT-I, Pharmacist, LVN, EMT-P, NP, DVM, PA, RCP,
MFT, DDS, LCSW, etc.
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Preferred
Skills,
Training,
Certs
17.
Logistics Section:Fulfillment
Date/Time
Required
Indicate
anticipated
mobilization or
duty date.
Anticipated
Length of
Service
Indicate days
or hours.
Quantity
11AUG11
Tracking # or
DHV Mission
Number
Required Skills,
Training, Certs
(e.g., PALS, Current ICU
experience, Languages,
ICS training, Addt'l Lic.
i.e., PHN, etc.)
Additional Instructions:
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Deliver to/Report to POC (Name, Title, Location, Tele#, Email, Radio, etc.)
3 PRIORITY: (E)mergent <12 hour (RIMS:FLASH/HIGH), (U)rgent >12 hour (RIMS: MEDIUM) or (S)ustainment (RIMS: LOW)
Staging & Deployment Details (Parking/staging location? Food/water provided? Housing Provided? Items personnel should bring? Etc.) Provide Additional on Separate Page, if needed.
6b. ORDER PERSONNEL REQUEST DETAILS
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Minimum Required
Clinical Experience
(1=current hospital,
2=current clinical,
3=current license,
4=clinical education)
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ORDER SHEET
____OF ____
Detailed Specific Description
(Facility: Type, Tent, Trailer Size etc.)
(Mobile Resources: Alternate Care Supply Cache, Mobile Field Hospital, Ambulance Strike
Team)
Approved Filled Back-
Ordered
11AUG11
6c. ORDER OTHER REQUEST DETAILS 17. Logistics Section: Fulfillment
NOTE: To be completed by the Level/Entity that fills the request (OA EOC, Region, State).
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Pr
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Quantity 2
Requested Tracking #
Estimated
Time of
Arrival
(Date & Time)
3 PRIORITY: (E)mergent <12 hour (RIMS:FLASH/HIGH), (U)rgent >12 hour (RIMS: MEDIUM) or (S)ustainment (RIMS: LOW)
2 QUANTITY: Number of individual items, caches, strike teams, or resources needed .
Expected
Duration of
Use:
Quantity
COST
Suggested Source(s) of Supply; Suitable Substitute(s); Special Delivery Comment(s): Deliver to/Report to POC (Name, Title, Location, Tele#, Email, Radio,
Product
(Ea, Cache,
Team)