Form Ics 213 Pr - Public Health Resource Request Form
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1
2PUBLIC HEALTH RESOURCE REQUEST FORM (ICS 213 RR)
1. Requestor Name/Organization:
2. Requestor Phone/Email:
3. Order (Use additional forms when requesting different resource sources of supply)
4. Resource Status (complete after resource
received/returned)
Detailed Item Description (Vital characteristics, brand,
Qty
UOM
specs, experience, size, etc.)
Received
Condition
Returned
Condition
Date/Time
Received
Date/Time
Returned
5. Requested Delivery Location/Address:
6. 24 Hour POC Name/Phone:
7. Suitable Vendor and/or Item Substitutes:
8. Approval Name:
9. Date/Time:
10. Incident/Facility Name:
11. Date/Time:
12. Resource Request Number:
13. Order Number:
15. Supplier Phone/Email:
14. Suggested Source(s) of Supply:
16. Notes:
17. Approval Name:
18. Date/Time:
19. Request Accepted:
Request Rejected:
20. Reason:
21. Requestor Notified (Date/Time):
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Parent category: Legal