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Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
The Agency/Organization submitting a resource request must exhaust all efforts to procure resources using their normal processes and will track costs to apply to federal/state reimbursement under their own application later, if they so choose to apply. The agency will also track donations to offset their match requirements for federal reimbursement later, as applicable.
The EOC can only submit resource requests using public monies for entities that are assigned or contracted to respond to the emergency formally. This notice is to inform non-governmental entities; especially private, for profit entities, that they need to be performing work under contract or at the express direction, control, and supervision of a public entity at the local, state, or federal levels. This form will ask you to identify the entity you are working under, but we currently do not require proof of contract. You are submitting this form in good faith and could be subject to penalty later if found you have used this form in a manner inconsistent with the intent explained herein or to gain a competitive advantage for profit or gain.
IF the Agency/Organization cannot find a resource under their normal procurement processes, THEN they may submit a resource request to the Emergency Operations Center. By submitting the online form at: http://www.berriencounty.org/FormCenter/Test-25/Resource-Request-125 (this form), the request will go to the Emergency Operations Center Logistics Section Chief (EOC LSC). The EOC LSC will work with the Health Dept LSC to classify the priority of the request compared against all of the other requests for resources. The agency/organization must provide sufficient information, provide cost justification related to what the resource will be used for, and quantity justifications to allow the EOC LSC to place an order .
IF the requesting agency is able to find the requested resource on their own while an order is pending, THEN they have the responsibility to notify the EOC LSC that the order can be reallocated to another entity or cancelled.
IF the EOC LSC is able to source the resource locally, the EOC LSC will either 1. procure the item and invoice the requesting agency, or 2. provide the requesting agency with the quote and contact information for the requestor to purchase on their own. IF the item is a scarce resource, the EOC Finance Section Chief is authorized by the requesting agency to make the purchase and invoice them. The justification for this agreement is so the scarce resource isn't purchased by another buyer while trying to work out the details of who will make the purchase (agency vs County).
IF the EOC LSC is unable to find a local source after exhausting a reasonable effort to find the resource, THEN the request will be escalated to the State Emergency Operation Center. The State has the ability to make purchases directly from the disaster contingency fund, so there will be no invoice generated if the State procures the resource unless the cost is later determined to be unallowable. If the cost is determined to be unallowable later, the requester is responsible for cost reimbursement to the State.
All scarce resources ordered and provided may not be ideal or even meet CDC PPE guidance requirements. We offer no guarantee of the quality or quantity of products or services provided and the requesting agency/organization understands we will fulfill the request in the best way we are able. The decision to use and the manner of use for the product/service delivered rests with the requesting agency.
The requesting agency/organization will be responsible for pick of supplies from a warehouse in Benton Harbor when it arrives.
By submitting this form, the requester agrees to these conditions.
Enter all data for the resource you are requesting. If the resource is a FEMA Typed Resource, please indicate that typing in the Resource Name field. Please use one form for each resource requested, do not batch different kinds of resources into one form.
Single Personnel = A Person to do a job. Team = A Team of People + their normal equipment. Contractual Service = Commercial service provided by a contractor. Equipment = A reusable resource. Supplies = Consumable/Disposable Items Other = Anything else from technical assistance to a request to release public information.
Indicate the date you last ordered this resource (if it is a repeated order).
Has your last order been fulfilled?
Are you entering this order because you aren't sure if the first order has been forgotten or ignored? Is this a re-entry of information?
The system we have is not a general shopping cart and we will not accept requests that are batched like "PPE supplies". We will not have requisite time to track you down to determine what that means and will not fulfill your request.
Copy and paste a link to the product type you are asking for so we can see an example.
Describe the attributes that are required and you cannot complete your mission if the resource does not have it. If it is a single personnel or team, include the skills or professional license required. The EOC will try to get the resource the best we can and we may get a product or service that is close to what you asked for. We cannot shop by brand. So, we need you to describe the features that are required so we look for those in a product. For example, we may find gloves that are non-sterile and not intended for medical use (like surgery) but they will work for PPE because all of the other attributes offer the wearer protection. If you require sterile gloves, then we will limit the search to that attribute.
Each is best for most packaged items.
If asking for boxes, drums, cases, etc. Describe how many items are expected to be in that bulk unit. ie a box of 50 ea vs a box of 100 ea.
Example: 4 staff are in close contact with 5 patients per hour in an 8 hr shift for the next 3 weeks. 4 x 5 x 8 x 21 = 3360 units + reasonable contingency supply of 640 = 4000 units. Alternatively, you may use the CDC burn rate calculator and attach it below. If doing this, you may attach the excel sheet below. Calculator found at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html
How many are in the high risk categories expressed by the CDC (ie ~65 years old, immuno- compromised, etc)
Check mark only those that apply to the job being planned, and how the resource will be used - not how the resource could be used.
The intent of this question is so we don't have to re-do what effort you've already made.
Provide sources you recommend we call to fulfill your request. This is intended for requests which require the EOC to make a request on your behalf, where you cannot do directly on your own, but you know who we should contact. The best example is a State defined Team, like MiMORT, or Volunteer Registry etc.
If we cannot find the exact resource you described above, or in a timely manner; describe acceptable substitutes you would accept?
The date you will or already did run out of supply (if this resource will replace supply)
The date that it is best to have by.
The date in which you will have a problem if not fulfilled by. (Given the understanding there is no guarantee the EOC will be able to fulfill by this date, or even at all).
You may describe the likely outcome here if we are unable to fulfill your order in time. You may also describe your "plan B" so we can sleep better at night if we can't find the resource in time.
ie. Reduce exposure to COVID-19 to Emergency Workers through the use of PPE and engineering controls
ie. Provide workers in high risk jobs (close contact with COVID19+ or symptomatic) with CDC recommended PPE.
ie. Meet a goal of providing 10 case workers 2 masks.
Describe
Provide the Entity in which you are providing service for under agreement.
You marked "other", please describe.
Upload any contracts, MOUs, LOAs that are relevant or any terms of a contract you may require us to include in an bid if that is needed.
Are you a Medicare Provider?
This field is not part of the form submission.
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