Emergency Preparedness

Surge Plan

MHOAC Request Order

Request #

MHOAC Assigned For Personnel, Supplies, Equipment, Pharmaceuticals

Kern County MHOAC XXXXX or XXXXXXXX S-SV EMS Agency 1700 Mount Vernon-Bakersfield CA 93306 Business Hours Agency Contact (Mon-Fri 0800-1700 Hours): XXXXXXXXXX, Regional Director/MHOAC Desk: (661) XXX-XXXX Sprint Cell (661) XXX-XXXX Office Staff: (661) XXX-XXXX Office Fax: (661) XXX-XXXX Office Satellite Phone: (661) XXX- XXXX

Facility:

Facility Requesting

Requester Name / Phone #: Fax: email: Date and Time of Request: Date and Time Item(s) are Required: How long are Items Required?

Location to be Delivered &Contact

Street / Bldg No / Room No & Contact Info

Personnel: Specialty

Quantity

Items: pharmaceuticals, supplies, or equipment: Type Quantity

Kind

Condition on Receipt

Has previous coordination been accomplished for these items? Yes

No

With Whom?

Revised: 9/2017

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