Form Ics 213 Pr - Public Health Resource Request Form Page 2
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2Public Health Resource Request Form Instructions
Purpose: The Resource Request (ICS 213 RR) is used to order resources and track resource status.
Preparation: The ICS 213 RR is initiated by the resource requestor, who will complete the “Requestor” section highlighted in light blue. Once the requestor
section is completed, the form is sent to the appropriate agency (e.g. Regional Resource Center, Public Health Emergency Operations Center, etc.) to be
completed by the Logistics or Command Staff. After the form is finalized, the requestor will be notified of the action taken and provided a copy of the form.
Distribution: This form is maintained in order to track resource status.
Box Number
Box Title
Instructions
1
Requester Name/Organization
Enter the name and organization of the requestor
2
Requester Phone/Email
Enter a phone number and email address for the requestor
Specify quantity, Unit of Measure (UOM), and item description. Examples of UOM
3
Order
include box, case, single, bottle, etc.
Enter date (m/dd/yy) and time (HH:MM – 24 hour clock) received/returned and condition
4
Resource Status (complete after resource
received/returned
received/returned)
5
Requested Delivery Location/Address
Enter location and address for delivery/reporting
6
24 Hour Point of Contact Name/Phone
Enter a POC name and a phone number where they can be reached 24 hours
Enter possible substitute vendors and/or items in case exact requested resource is not
7
Suitable Vendor and/or Item Substitutes
available
Enter the name of the official authorizing the request on behalf of the requesting
8
Approval Name
organization
9
Date/Time
Enter the date (m/dd/yy) and time (HH:MM – 24 hour clock) for request approval
10
Incident/Facility Name
Enter the name assigned to the incident or facility
Enter the date (m/dd/yy) and time (HH:MM – 24 hour clock) the request was received
11
Date/Time
12
Resource Request Number
Generate a unique number (the first request should be 1)
13
Order Number
Enter a unique order number (e.g. from inventory mgmt system)
14
Suggested Source(s) of Supply
Enter source(s) for the resource requested
15
Supplier Phone/Email
Enter contact information for source of supply suggested in Box 14
16
Notes
Enter any relevant notes regarding the request
Enter the name of the official recognizing the request (e.g. logistics section chief or
17
Approval Name
command staff)
18
Date/Time
Enter date (m/dd/yy) and time (HH:MM – 24 hour clock) for request recognition
19
Action Taken
Check “accepted” or “rejected” based on decision by command staff
20
Reason
Enter reason for action taken if “rejected” in Box 19
21
Requestor Notified
Enter the date and time the requester was notified of the action taken in Box 19
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Parent category: Legal