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Medical and Health Resource Request (PROVIDER to MHOAC)	RR MH (10/13)
1. Incident Name:	2a. DATE:	2b. TIME:	2c. Requestor Number: (Assigned by Requesting Entity)
3. REQUESTOR:
NAME:
AGENCY:
POSITION:
PHONE:
EMAIL:
4. DESCRIBE MISSION OR TASK:
5. ORDER SHEET(S) ATTACHED:
6. ADDITIONAL CONSIDERATIONS:
SUGGESTED SOURCE(S) OF SUPPLY:
SUITABLE SUBSTITUTE:
SPECIAL DELIVERY COMMENT(S):
FOR PERSONNEL REQUESTS:
7.
8. COMMAND/MANAGEMENT REVIEW: Name, Position, & Signature: (Signing indicates the above statements have been verified and the request has been approved.) NAME: POSITION: SIGNATURE:

5. ORDER:
Line #	Priority*	DETAILED SPECIFIC ITEM DESCRIPTION: Supplies: characteristics, brand, specs, etc. Rx: Drug Name, Dosage Form, UNIT OF USE PACKAGE or Volume, etc. Personnel: experience, licensure, etc.	Kind Supplies: Product class (bx, cs, ea, etc.) Rx: Strength Personnel: Specialty	Type Supplies: # per product class Rx: Unit, concentr. Personnel: certs, etc.	Quantity** Requested	Expected Duration of Use:	Delivery Location	Delivery Point of Contact (Name, phone, fax, email)

*PRIORITY: (E)mergent <12 hour (RIMS: FLASH/HIGH), (U)rgent >12 hour (RIMS: MEDIUM) or (S)ustainment (RIMS: LOW)

**QUANTITY: Based upon a unit of EACH; Pharmaceuticals are based upon a single regimen of the requested unit.

Send completed form to Medical and Health Operational Area Coordinator (MHOAC) at: