Resource Request Form - Pennsylvania Emergency Management Agency
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1
2COMMONWEALTH OF PENNSYLVANIA
Refer to page 2 for instructions
PENNSYLVANIA EMERGENCY MANAGEMENT AGENCY
RESOURCE REQUEST FORM
I. REQUESTING ASSISTANCE (To be filled out by the Requesting Political Jurisdiction or State Agency)
(1) Date / Time:
(2) Incident Identification Number:
(3) Name and Organization:
(4) Title:
(5) Municipality:
(6) County:
(7) State Agency:
(8) Phone No:
(9) Fax No:
(10) E-mail Address:
II. REQUESTING ASSISTANCE – REQUESTED RESOURCE (To be filled out by the Requesting Political Jurisdiction or State Agency)
(1) Description and Capability of Requested Assistance:
(2) QTY:
(3) Date / Time Needed:
(4) Municipality or County Declaration of Emergency?
(5) Priority:
Lifesaving
Life Sustaining
Property Preservation
Incident Stabilization
Planned Event
(6) Was Mutual Aid Attempted?
(7) Was the Organization’s Procurement Process Utilized?
(8) Logistics (List any logistical needs associated with the request):
(9) Delivery Site Location:
(10) Site Point of Contact (POC):
(11) Site POC Phone No:
(12) Authorized Representative Signature:
(I understand that costs to the requestor may be incurred or associated
with this request)
III. REVIEW (If Submitted by Municipal Jurisdiction, County Jurisdiction will Review Request)
(1) County EMC or Designee Signature:
Date / Time:
County EMC or Designee Print:
Phone No:
Comments / Justification:
(2) PEMA Area Office or Designee Signature:
Date / Time:
PEMA Area Office or Designee Print:
Phone No:
Comments / Justification:
IV. SOURCING THE REQUEST – REVIEW / COORDINATION (PEMA Headquarters Only)
(1) Review:
(2) Source:
(3) Assigned to:
OPS Review by: ________________________
ESF:
_________________________
Procurement
Other: _________________________
LOG Review by:________________________
Mission Assignment
(4) Costs:
Costs Incurred by:
Other Coordination: ____________________
Other
(5) Mission Number:
(6) Authorized PEMA Representative Signature:
Date / Time:
V. ACTION TAKEN (PEMA Headquarters or Assignee Response)
Accepted
Rejected
Requestor Notified
Reason / Disposition:
Requestor notified by whom:________________ Date / Time:___________________
Revision 3-1-14
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