COVID-19 Resource Request Form

AzCHER may be able to assist your organization if it is encountering issues with securing key resources due to the COVID-19 pandemic, such as surgical masks, isolation gowns, or cleaning supplies.

Once your organization has exhausted all other avenues of securing the needed resources (such as by working within the healthcare system or your organization’s sister facilities, and by contacting all contracted vendors), please complete ICS Form 213 RR and submit it to [email protected].  Your requested item(s) will be placed on the AzCHER website’s Resource Request Log so that potential donors will have visibility into the healthcare delivery system’s needs.

Once you submit ICS Form 213 RR, AzCHER will notify your local public health department.  Public health may have resources such as the Strategic National Stockpile from which to draw in emergencies, and/or may be able to work with county emergency management to meet your resource needs.

Instructions for Completing ICS 213 RR

Complete ONLY the following sections.

  • #1 – Incident Name = COVID-19
  • #2 – Date and Time you are completing the form
  • #4 – Your Order:
    • Quantity = the number of items needed
    • Kind of Resource = the general category of supply/equipment, like “respirator”
    • Type of Resource = a more specific characterization of the kind of resource, such as “N95”
    • Detailed Item Description, such as brand or size
    • Do not complete the Arrival Time and Cost sections.
  • #5 – Requested Delivery / Reporting Location = where resources should be sent
  • #7 – Requested by Name and Position = Person requesting and their contact information
  • #8 – Priority = Urgent, Routine, or Low

Save and submit your completed form to [email protected]. Your regional manager will reach out to you within 24 to 48 hours.