Form no. 07800 CNDH-IMU 11/2016
Inchokma Mobile Unit Request Form
Date:
From (Division/department/area):
Contact person: Title:
Phone: Email:
Event information: Note: Form should be submitted at least three weeks in advance of request unless a rush justification is supplied.
Name:
Date: Start time: End time:
Location:
Please check all that apply:
Type of service request:
Medical Dental Health screening Immunization Other:
Age range of participants:
0-11 12-18 18-older Elders
Is there access to power sources? Yes No If yes, list specific types of power available:
Is there network/data connection available? Yes No if yes, please specify types available:
Purpose of event: (justification needed if rush approval requested)
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Internal Use Only
Date received: ___ Approved
Received by: ___ Disapproved
Event comments:
the
Chickasaw Nation
Department of Health
