KITSAP COUNTY EXTERNAL RESOURCE REQUEST FORM (ICS 213 ERR)
1. Mission Number & Incident Name:
2. Date & Time: (mm/dd/yyyy - 00:00)
20-0265 Novel COVID-19
4. Resource Requested (attach additional sheet if necessary and document here)
Requester
a. Qty.
b. Kind
(if known)
C. Type
(if known)
6. Have you tried to source these items through commercial resources?
Internal use
Yes
No
What issues did you encounter?:
Insufficient stock,
Long Delivery Timeframe,
Inflated price, unacceptable,
Other, please explain in box #8
8. Suggested Sources for PPE, and or Explain 6 & 7b need for N/KN95 masks:
10. Requesting Agency Name and Address: (Address/landmarks etc.)
12. Requester Name, Position, phone, and email:
Finance
Logistics
14. EOC/ECC Logistics Tracking Number:
EOC
SHADED AREA f & g TO BE FILLED BY LOGISTICS SECTION
Needed Date & Time
d. Detailed item description and / or of task to be accomplished:
(Vital characteristics, brand, specs, experience, size, etc.)
5a. For Test Kit Requests: (summary of the situation, project future needs) Tests used for:
3. Weekly PPE Inventory & Burn Rate Form
Submitted Within Last 7 days:
Yes
No
e. Requested
Patients
General public
7a. Priority:
7b. Covid
Status:
g. Cost
f. Estimated
5b. Current test supply chain sources contacted:
Life Saving
Incident Stabilization
Property Preservation
Positive or suspected cases (social distance and basic PPE OK)
Positive or suspected cases (extra PPE, N/NK95s needed, explain in box 8)
No known or suspected cases
9. Requester is willing to provide funding if required:
Yes
If “No”, explain:
11. Point of Contact for Pickup or Delivery Location: (Name, phone and email)
13. Signature of Requester: (please type)
15. Name of Supplier / POC, Phone / Fax / Email:
16. Notes:
17. Approval Signature of Logistics Section Chief / or assigned representative: (please type)
19. Notes:
18. Date & Time: (mm/dd/yyyy – 00:00)
20. Finance Approval Signature: (please type)
21. Date & Time: (mm/dd/yyyy – 00:00)
22. Approval Signature of EOC Director:
No