Resource Request Form

Resource Request Form

As a member of SVHC, regional resources are available to organizations upon request. Please utilize the form below to request resources. For any additional questions please email Jeff McKinney at jmckinney@vaems.org
Resources Being Requested

Asset Requests
This request form is for large or regionally owned assets located in warehouses across the SVHC region. Please reference the SVHC Resource Guide when requesting these assets, https://nspa1.org/wp-content/uploads/2023/12/SVHC-Resource-Guide-2023-9-25-23.pdf.

This form should NOT be used for emergencies; all emergency requests should be made through the RHCC Hotline, 1-866-679-7422. Please allow us up to 48 hours to process your request.

Note: Most of these resources take time to mobilize and deploy. After you submit your request, the Inventory or RHCC Manager will contact you regarding your specific request.
What Regional Asset(s) is being requested?*
Supporting Details / Notes*
List name of specific type of training, exercise, special event, other, etc.
Name*

First NameLast Name
Email*
example@example.com
Organization*
Phone Number*
Please enter a valid phone number.

Training & Exercise Equipment

Partners in good standing within the The Southwest Virginia Healthcare Coalition (SVHC) region can request a variety of equipment to support their training and exercise programs. Please complete the fields below. Following your submission, someone will reach out to you to coordinate information regarding your request. All items should be returned in the same condition/manner they were issued. Please contact Monica McCullough, mmccullough@vaems.org with any concerns.
Name*

First NameLast Name
Requesting Agency / Organization*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Intended use/purpose for resources being requested*
List name of specific type of training, exercise, special event, other, etc.
Date of Event*

MonthDayYear
Date
What item(s) is being requested?*
Return Date*

MonthDayYear
Date

Emergency PPE Request
SVHC maintains an emergency cache of personal protective equipment for regional partner organizations. To request these items, your organization must:
- A current MOU (hospital) or Letter of Support on file
- Complete the form below in its entirety
- Have an understanding of your organization's burn rate. Click here to learn more about burn rates.
Once you submit your request, an SVHC staff member will contact you within 48 hours. Organizations are expected to send someone to pick up any requested items in Roanoke or Abingdon. All organizations picking up PPE will be required to sign this waiver upon receipt of the items.

This form should NOT be used for emergencies; all emergency requests should be made through the RHCC Hotline, 1-866-679-7422. Please allow us up to 48 hours to process your request. If you have any additional questions, please get in touch with the Inventory or RHCC Manager.
Name*

First NameLast Name
Title*
Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
ICS 213 Resource Request*
Which vendor(s) have you contacted to purchase PPE?*
Please list name of company, and phone number
Reasons Vendor(s) are unable to fulfill the order*

Order canceled by vendor(s)Product or suitable alternatives not available from vendorsProduct on backorder from vendors (if so, please list date available below)Other
Based on your answers above, what measures have been taken to establish a long term solution to PPE needs with your vendors*
As of the request date, what is your current supply of each item? *
Current Number of Positive Patients*
Are the items being requested being used for COVID-19 only? (If no, please explain)*
What PPE conservation measures have you put into place in your facility?*

Disclaimer
By submitting this form, you agree to the terms outlined in the form and the waiver(s) listed for the specific item(s) you have requested. Please review that guidance before clicking submit.
Upon receipt of the item(s), you will be asked to sign the waiver reflected above.
Should be Empty:

Resource Request Form

Asset Requests

Training & Exercise Equipment

Emergency PPE Request

Disclaimer