Fillable COMPLETED BY REQUESTOR Resource Request Form 213RR for (County of Santa Clara)

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COMPLETED BY REQUESTOR Resource Request Form 213RR for (County of Santa Clara)

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The COMPLETED BY REQUESTOR Resource Request Form 213RR for (County of Santa Clara) form is 8 pages long and contains:

  • 3 signatures
  • 15 check-boxes
  • 150 other fields

Country of origin: US
File type: PDF

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County of Santa Clara
Emergency Operations Center (EOC)
Resource Request Form 213RR
for Medical Personnel (COVID-19)
COMPLETED BY REQUESTOR
1. Incident Name
2019 Novel Corona Virus (COVID-19)
2. Date Initiated
3. Time Initiated
4. Tracking Number
(Completed by OA EOC)
5. Requested By (name, agency, position, email, phone)
How to use the EOC Form 213RR
Purpose
The EOC 213RR is used to request non-mutual aid supplies, services,
personnel, teams, equipment, utilities, fuel, facilities, or any other resource or
incident management activity required from the Operational Area (OA.)
When to use
The Form 213RR may be used anytime during any Operational Period. If the
OA EOC is not activ
ated the Duty Officer will serve to coordinate the request.
Prepared by
Any EOC position or agency requesting resources from the OA
6. Prepared by (name, position, email, phone)
Approved by (A) Executive or Supervising Official at requesting agency or (B) a
Section Chief
of the requesting EOC or (C) Deputy County Executive if request is from a County Department and is
requesting PPE.
Routed to
Logistics Section - SCC Resource Tracking Unit
Send signed form via email to: resourcetracking@eoc.sccgov.org
Filed with
Logistics Section Resource Tracking Unit / Planning Section
Documentation Unit
7. Approved by (name, position, email, phone)
Signature:
User Notes
The EOC is a last resort provider and you may be responsible for the cost of
the requested items. Please check that all pages and necessary fields are
completed. Page 1 is required for all requesters. Please be sure the form
has proper signatures for Approved By (box 7). The last page is completed
by the OA EOC.
Requesting Agency / EOC Section
REQUESTED RESOURCE DETAILS
8. Qty/Unit
9. Resource Description Note: See pages 2 and 4 -
8 to provide additional information for personnel requets
10. Arrival (date/time) 11. Priority 12. Est’d Cost
Now
High
(0-4 hours)
Medium
(5-12 hours)
Low
(12+ hours)
13. Deliver to (name, agency, position, email, phone)
14. Location (address or lat./long., site type)
15. Substitute/Suggested Sources (name, phone, website)
16. Supplemental Requirements (include details in #17) 17. Special Instructions
Equipment Operator
Fuel
Fuel Type
Meals
Water
Lodging
Power
Maintenance
Other
Form 213RR
County of Santa Clara – Emergency Operations Center (EOC)
Last Revised: 12/3/2020
Page 1 of 8
click to sign
signature
click to edit
Disaster Service Activity
EOC Tracking #
Report to
Contact Number
Location to report
Date(s) to report
Schedule
Duration
Duties
Items to bring with you
Types of PPE provided
Amenities (ie break room,
lunch provided, etc)
If you have any questions regarding this request, please email the EOC personnel unit at
personnel@eoc.sccgov.org.
Thank you in advance for your help,
EOC Personnel Unit
Last Revised: 12/3/2020
Page 2 of 8
TO BE COMPLETED BY A
LL REQUESTORS
County of Santa Clara
Emergency Operations Center (EOC)
Resource Request Form 213RR
COMPLETED BY OA EOC or DUTY OFFICER
OA EOC
Logistics
Section
18. Order Placed By
(name, position, agency, phone, radio, email)
19. Method of Procurement
(filled-in house, agreement, purchase, etc.)
20. Supplier Name / Point-of-Contact Information
(name, address, phone, fax, email)
21. Logistics Section Remarks
22. Logistics Section Chief Approval
(print and sign)
OA EOC
Fin/Admin
Section
23. Finance/Admin Section Chief Remarks and Approval
(print and sign)
Date/Time
OA EOC
Management
Section
24. EOC Director/County Executive Remarks and Approval
(print and sign)
Date/Time
OA EOC
Logistics
Section
25. Logistics Section Final/Demobilization Remarks
Date/Time
Form 213RR
County of Santa Clara – Emergency Operations Center (EOC)
Last Revised: 12/3/2020
Page 3 of 8
PART 1. TO BE COMPLETED BY ALL REQUESTORS
Requestor Details
Date of Request:
Request Point of Contact:
Requestor Email:
Requestor Phone:
Requesting Facility Details
Facility Name:
Facility Type:
County:
Total Facility Capacity:
Number of Free, Patient-Ready Beds:
Does the Facility Currently Have
COVID-19 Positive Patients (yes/no):
Deployment Details
Requested Deployment Dates:
Requested kind of staff and number of each:
Staff classification (e.g. RN, LVN, CNA)
Number
Total Number of Staff Requested:
Request Details
Anticipated duration of staffing need (max = 72 hours)
Reason for staffing request
(Please note that requests to provide staff for performing
COVID testing or to cover staff while they get COVID
testing are not appropriate).
If staffing is provided to my facility by the County, I
confirm, on behalf of my facility, that I will fully
reimburse the County for all costs to the County for ALL
staff and goods. I acknowledge that the County may
terminate this arrangement at any time.
Yes No
Initial here__________
Maximum hourly rate
$
Last Revised: 12/3/2020
Page 4 of 8
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signature
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Previous attempts
Have you attempted to obtain staffing from
parent corporation and sister institutions?
Yes No No sister institutions
Have you contacted and attempted to obtain
staffing from at least 3 agencies? [REQUIRED
PRIOR TO REQUEST]
Yes No
Agency name:
Agency contact:
Date of contact:
Reason for refusal:
Agency name:
Agency contact:
Date of contact:
Reason for refusal:
Agency name:
Agency contact:
Date of contact:
Reason for refusal:
Requested Coverage
Shift Days of the Week (check all that apply)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
AM Shift
Hours
From (start
time):
To (end
time):
Duration
(hours):
Kind of Staff Requested for AM Shift # of Staff Requested for Shift
PM Shift
Hours
From (start
time):
To (end
time):
Duration
(hours):
Kind of Staff Requested for PM Shift # of Staff Requested for Shift
Last Revised: 12/3/2020
Page 5 of 8
PART 2. TO BE COMPLETED BY ACUTE CARE HOSPTIALS ONLY [REQUIRED BY STATE OF CA]
PROCEED TO PART 3 FOR ALL OTHER REQUESTORS
Bed Availability
Number of available beds:
Number of additional beds if
provided staffing:
Current % Patient Occupancy:
Mitigation Plan
Number of available beds:
Number of additional beds if provided staffing:
Current % Patient Occupancy:
Has the hospital cancelled all elective surgeries in order to free up bed
space and allow for staffing resources redirection to needed units?
Yes No
Has the hospital cancelled all outpatient procedures in order to free up
bed space and allow for staffing resources redirection to needed units?
Yes No
Has the hospital activated their previously vetted and approved surge
plan?
Yes No
Does the hospital have other hospitals in their network that could
provide additional staffing to the hospital in need?
Yes No
Does the hospital have a “Program Flex” for staffing approved by
California Department of Public Health (CDPH)?
Yes No
What is the hospital’s long-term strategy to continually staff the facility
to provide appropriate level of care for the patients within the
hospital?
Last Revised: 12/3/2020
Page 6 of 8
PART 3. TO BE COMPLETED BY ALL REQUESTORS
Signature _____________________________________________ Date________________
Instructions For Arrival
(eg. instructions for accessing the facility, parking, security, point of contact):
Additional Information
Information not captured in this form or the corresponding Resource Request
Last Revised: 12/3/2020
Page 7 of 8
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signature
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Please provide answers to the following questions to aide in the adjudication of your
request for staffing. ALL REQUESTS MUST BE ACCOMPANIED BY A SALESFORCE NUMBER or
the request cannot be adjudicated.
Salesforce RR# (Requester to leave blank. Filled in by MHOAC.): ___________
Facility Name: ______________
Number of Available Beds: ______________
Number of additional beds if provided requested staffing: ________________________
Current % Patient Occupancy: ___________________
- Facility Census: _______
o COVID + residents: _______
o PUI Residents: _______
- Total Patient Care Staff: ______
o COVID + Staff: ______
o Staff Unavailable to work (COVID or other): ______
- Has the facility stopped taking new admissions?
- Is the facility following their mitigation plan?
- Does the facility have sister facilities or a network of facilities that could
provide additional staffing to the facility in need?
- Has the facility reached out to private staffing contract agencies to provide
additional staffing in the facility?
o Which agency?
o Why is this agency unable to provide assistance?
* Please list each agency separately
- What is the facility’s long-term strategy to continually staff the facility to
provide appropriate level of care for the patients?
Please provide the answers to your MHOAC and your local CDPH District Office
representative. As a reminder, state sourced staffing is meant to fill short term
emergency staffing gaps and is not meant as a long term staffing resource.
Last Revised: 12/3/2020
Page 8 of 8
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COMPLETED BY REQUESTOR Resource Request Form 213RR for (County of Santa Clara)

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Completed 7 March 2021

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