Fillable Androscoggin County EMA ICS 213 RR-PPE (County of Androscoggin)

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Androscoggin County EMA ICS 213 RR-PPE (County of Androscoggin)

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The Androscoggin County EMA ICS 213 RR-PPE (County of Androscoggin) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for County of Androscoggin

BROWSE COUNTY OF ANDROSCOGGIN (ME) FORMS

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Qty
YES
NO
Disposable Protective Suits (L)
YES
NO
YES
NO
Primary POC Name:
Primary POC Phone
Secondary POC Name:
Secondary POC Phone
Date:
Time:
Date:
Request Accepted:
Request Rejected: Date:
Time:
Date: Resource Req #:
Logistics or Command
Delivery Location/Address:
Reason/Justification:
Approver Name:
Submitted By (Name):
Time:
FOR INTERNAL USE ONLY:
Incident/Facility Name: COVID-19 Response
EOC POC Name/Phone/Email:
Time:
Coordinating Instructions:
Email:
Alternate Phone
Email:
Alternate Phone
Nitrile Gloves (L)
Has the requesting agency/facility
exhausted on-hand resources?
Nitrile Gloves (XL)
Disposable Shoe Covers (One Size)
Gowns (One Size)
Sanitation Wipes
Hand Sanitizer *Not available
Disinfectants
Disposable Protective Suits (2XL)
Disposable Protective Suits (3XL)
Disposable Protective Suits (4XL)
Nitrile Gloves (S)
Nitrile Gloves (M)
Androscoggin County EMA ICS 213 RR-PPE
Requestor
Requestor Name/Organization: Requestor Phone/Email:
Order Details Request Process Criteria
Detailed Item Description
Does the requesting agency/facility
have an active Respiratory
Protection Program (RPP) in
place?
N95 Masks (XS)
N95 Masks (S)
N95 Masks (Universal)
Surgical Protective Masks (Universal)
Face Shields (One Size)
Disposable Protective Suits (M)
Has Fit Testing been conducted at
this agency/facility within the 12
months prior to the date of this
request?
Disposable Protective Suits (XL)
*Not available
*Not available
*Not available
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Androscoggin County EMA ICS 213 RR-PPE (County of Androscoggin)

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Completed 17 July 2020

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