Resource Request Questions


Incident Name:

Priority

• When do you need this request fulfilled?
o 0-4 hours
o 4-8 hours
o 8-12 hours
o 12-36 hours
o Longer than 36 hours

Justification
• Does the county or local jurisdiction have the ability to contract for these resources?
o Yes
o No

• Have you exhausted all mutual aid options in the surrounding counties?
o Yes
o No

• Additional justification for the requested resource(s):
Justification Examples:
Local jurisdiction does not have this resource...
All existing resources have been contracted out...
Surrounding counties are also impacted...
No mutual aid is available...

Requesting Jurisdiction
• Requester Agency:
• Operational Area:

Requested Resources
• Resource Name:
• Quantity Requested (ea):
• Detailed Resource Description: (Vital characteristics, brand, specs, experience, size, etc.)
• Is an operator needed for this resource?

• Request Summary (Why is this resource needed and what will it do):

• Actions taken on this request so far (what have you done to obtain the resource on your own)?

Requester Information
• Requester First & Last Name:
• Requester Email:
• Requester Phone:
• Requester Title:

Delivery Information
• Recipient First & Last Name:
• Delivery Recipient Email:
• Delivery Recipient Phone:
• Delivery Recipient Title:
• Delivery Recipient Entity Name:
• Delivery Location:
• Delivery Notes:

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FOR PARISH GOHSEP AND STATE EOC AUXCOMM USE
RESOURCE REQUEST FORM
              OPERATIONS SECTION • PHONE: (225) 925-7500 • FAX: (225) 925-7501

 GENERAL INFORMATION    RESOURCE DESCRIPTION & DELIVERY INSTRUCTIONS
INCIDENT #:

  {var Incidentnum}
  {var DESC-DELIVERY}
REQUESTER NAME:

  {var RequesterName}
PARISH:

  {var PARISH}
DATE/TIME NEEDED:

  {var RDateTime}
DURATION NEEDED:

  {var Duration}
TRACKING # (DTG/PARISH):

  {var TrackongNum}

IS DELIVERY REQUIRED:   {var DeliveryNeeded}
RESOURCE TYPE REQUESTER POC DELIVERY INFORMATION

 

  {var rESOURCEtYPE}

FIRST NAME:

  {var thename2}
LAST NAME:

  {var LastName}
AGENCY:

  {var Agency}

PHONE:

  {var ReqPhone}

ALT. PHONE:

  {var ReqPhone2}

E-MAIL:

  {var ReqPhone3}
POC NAME:

  {var POCname}
E-MAIL:

  {var POCemail}
PHONE:

  {var POCphone}
ALT. PHONE:

  {var POCaltphone}
NAME OF SITE:

  {var POCSite}
ADDRESS:

  {var DESC-DELIVERY2}
 
PARISH AUTHORIZATION
SIGNATURE:

  {var Signsture}
POSITION/TITLE:

  {var Position}
GOHSEP Resource Request  v 0.1