Fillable Resource Request Form 213RR for Goods & Supplies (County of Santa Clara)

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Resource Request Form 213RR for Goods & Supplies (County of Santa Clara)

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County of Santa Clara
Emergency Operations Center (EOC)
Resource Request Form 213RR for Goods & Supplies (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 3 for PPE/Medical Supply requests.
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: 12/8/2020
Page 1 fo 4
12:00 AM
REQUESTOR'S NAME
REQUESTOR'S AGENCY
REQUESTOR'S POSITION
REQUESTOR'S EMAIL
REQUSTOR'S PHONE
USUALLY SAME AS ABOVE
ADMINSTRATOR/SUPPLY COORDINATOR ETC
(PLEASE MAKE SURE THE BOTTOM FIELD IS SIGNED)
UNITS
NAME OF POC TEST KITS
PLEASE PLACE
TOMORROW'S DATE
AND TIME.
THESE ARE NOT
GUAREENTEED BUT IT
WILL HELP STREAMLINE
THE PROCESS
ADMINSTRATOR/SUPPLY COORDINATOR NAME
LOCATION OF FACILITY (PLEASE NOTE THAT YOU WILL
STILL BE REQUIRED TO PICK THE TEST KITS UP)
click to sign
signature
click to edit
213RR COVID-19 – PPE Request Details
PPE / Testing Supplies Requests
Entity Name
Entity Type
☐ ALF ☐ EMS ☐ SNF ☐ Hospital ☐ Laboratory ☐ First Responder ☐ Mortuary ☐ Home Health
☐ City/Jurisdiction ☐ Private Provider/Dentist ☐ School ☐ County of Santa Clara Department
☐ Other:
By requesting PPE or other supplies from the Emergency Operations Center of the County of Santa Clara, I certify that on behalf of
the above-named entity (“Entity”) that:
1. The PPE requested will be used for a medical need/procedure that if not performed could result
in serious injury or death.
☐YES ☐ NO ☐N/A
2. The Entity has completed the required PPE Survey (daily for hospitals, weekly for SNFs, one
time for all others if quantity thresholds are met).
☐YES ☐ NO ☐N/A
3. The Entity has tried extensively through all known vendor options and has exhausted all
possible PPE procurement options prior to making this request.
☐YES ☐ NO ☐N/A
4. The Entity understands that it may be billed, and the Entity agrees to pay the County’s costs for
this PPE request in the future.
☐YES ☐ NO ☐N/A
5. PPE will be used for the provision of clinical services in Santa Clara County.
☐YES ☐ NO ☐N/A
6. The Entity understands that (1) PPE and other supplies provided be the County were received
from donations, mutual aid, and other sources, (2) the County makes no representation or
warranty of any kind regarding the supplies, including but not limited to any representation or
warranty regarding quality or fitness for use, and (3) the Entity should inspect any supplies
received from the County and make its own independent determination as to the supplies’
suitability for the Entity’s use.
☐YES ☐ NO
7. I have the authority to legally bind the Entity. The Entity agrees to indemnify, defend, and hold
harmless the County, its officers, agents and employees (collectively, “County parties”) from
any claim, liability, loss, injury, or damage arising out of, or in connection with, County’s
provision of PPE and/or other supplies to the Entity and the Entity’s use of such supplies. The
Entity shall reimburse the County for all costs, attorney’s fees, expenses and liabilities incurred
with respect to any litigation in which the Entity contests its obligation to indemnify, defend
and/or hold harmless the County parties and does not prevail in that contest.
☒YES ☐ NO
Additional Comments:
Last Revised: 12/8/2020
Page 2 fo 4
NAME OF FACILITY
PLEASE CHECK THE APPROPRIATE TYPES
High-Priority PPE Items
Category
Item Type
Size
Quantity Requested
Eye Protection
Goggles
ONE SIZE
ea
Eye Protection
Face Shield
ONE SIZE
ea
Gloves
Gloves Nitrile
S
ea
Gloves
Gloves Nitrile
M
ea
Gloves
Gloves Nitrile
L
ea
Gloves
Gloves Nitrile
XL
ea
Gown
Disposable Gowns
ONE SIZE
ea
Gown
Washable Gowns
ONE SIZE
ea
Mask N95
3M N95 1860S (small)
ONE SIZE
ea
Mask N95
BYD N95 Mask
ONE SIZE
ea
Mask N95
NIOSH N95 Mask (non-
vented)
ONE SIZE
ea
Mask Non-N95
Ear-loop Face Mask -
Surgical/Procedure
(medical grade)
ONE SIZE
ea
Testing Supplies
Nasopharyngeal Swab
N/A
ea
Testing Supplies
Oropharyngeal Swab
N/A
ea
Testing Supplies
Microtest Remel M4RT
VTM (non-refrigerated)
N/A
ea
Testing Supplies
Viral Transport Medium,
other (non-refrigerated)
N/A
ea
Non-Priority PPE Items
Category
Item Type
Size
Quantity Requested
Coverall
Coveralls
ONE SIZE
ea
Hair Covers
Hair Covers
ONE SIZE
ea
Mask Non-N95
Ear-loop Face Mask (non-
medical grade)
ONE SIZE
ea
Mask Non-N95
Dust Face Mask
ONE SIZE
ea
Sanitizer
Hand Sanitizer
1 GAL
ea
Sanitizer
Hand Sanitizer
12 OZ
ea
Sanitizer
Hand Sanitizer
4 OZ
ea
Sanitizer
Disinfectant Wipes
ONE SIZE
ea
Shoe Covers
Shoe Covers
ONE SIZE
ea
Last Revised: 12/8/2020
Page 3 fo 4
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: 12/8/2020
Page 4 fo 4
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Resource Request Form 213RR for Goods & Supplies (County of Santa Clara)

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Completed 7 March 2021

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