COVID-19 –STATE / LOCAL RESOURCE REQUEST FORM A. REQUEST FOR ASSISTANCE (To be completed by requesting State DOH) ALL FIELDS REQUIRED 1. Requestor’s Name (Please print) 2. Title 3. Phone No. Donnie Haynes Preparedness Director 304-558-6900 4. Requestor’s Organization 5. Cell Phone No. 6. Email Address WV DHHR 304-395-2592 Donnie.w.haynes@wv.gov 7. Description of Requested Assistance (describe resource type and need in plain language – no acronyms). Provide justification for request in detail. First shipment received on March 16, 2020 was woefully under the allotment that was promised to WV. See attached supplemental request letter for specifics. WV just received the first confirmed lab tested case on this day. Based on the current state of COVID-19 and the after evaluating the state of the WV DHHR supply of Personal Protective Equipment (PPE), this request in full is required to keep WV Healthcare systems open and operational. Failure to meet this request could pose severe negative consequences to our healthcare system and have a drastic impact on the public. This material is intended for healthcare use and we have attempted to obtain the requested materials through other means and have exhausted all options. We are in desperate need of at least 300,000 N95 masks, 300,000 surgical masks, 50,000 goggles/face shields, 200,000 gowns, 2000 boxes medium gloves, 2000 boxes large gloves, and 2000 boxes xlarge gloves. By having this request filled, it will ensure community testing strategies can be initiated in all 55 counties. Failure to grant this request will likely have grave impacts on the healthcare system, and citizens of this state. X N-95 Masks X Goggles X Gowns ☐ Medical Providers ☐ Technical SME 10. Date and Time Needed ASAP By 12. Delivery Site Location (Address, City, Zip) 8. Requested Item X Gloves: ☐ Small X Medium X Large X X-Large 11. Estimated Duration of Need 180 (days) 13. Site Point of Contact (POC) Name and Title WVDHHR Operations – Material Management 900 Bullitt Street Charleston, WV 25301 Christopher Rawlings 14. Delivery Site Location (☐USNG or ☐Decimal Degrees) 15. Site 24 Hour Phone No. 16. Site email Address 304-558-3417 Christopher.d.rawlings@wv.gov B. HHS REGIONAL REVIEW (To be completed by HHS Region where request was initiated) Reviewed By (Name & Title) Disposition Date and Time ☐ Sent to IMTNAT ☐ Sent to SOC/IST Priority ☐ ASPR/FEMA RSP POCs notified ☐ High ☐ Medium ☐ Low Regional Approving Official (Name, Title, Date, Time) ASPR Region Request Number HHS RFR ID Number C. HHS RCB/SNS REVIEW (To be completed by RCB/SNS Section only) Received By (Name & Title) 1. Resource Typing/Adjustment 2. Special Instructions Entered in EMPortal by (Name & Title) Form COVID-19 State RFR v1 Date and Time Date and Time Created 3/05/2020 COVID-19 –STATE / LOCAL RESOURCE REQUEST FORM Disposition ☐ New Request ☐ Assigned ☐ Tasked to: _________________________________ ☐ Need More Information ☐ Out for Delivery ☐ En-route ☐ On Hold ☐ Complete ☐ Request Withdrawn ☐ Demobilized ☐ In Process ☐ Cancelled Assigned To (Name and Title) Point of Contact (Name and Title) 24-Hr. POC Phone Approved By (Name & Title) Date and Time 3. Cost Estimate 4. Priority ☐ High Low ☐ Medium ☐ State Government Tracking Number D. STATE GOVERNMENT REVIEW (To be completed by requesting State - Department of Health Agency) Received By (Name & Title) Disposition Date and Time ☐ Requested Federal Resources ☐ Filled with Local Resource(s) ☐ Filled with State Resources ☐ Denied Assigned To (Department Name) Point of Contact (Name and Title) 24-Hr. POC Phone Approved By (Name & Title) Date and Time F. REQUESTOR NOTIFIED (To be handled by HHS RCB/SNS Logistics) Region Notified By (Name & Title) Date and Time State Notified By (Name & Title) Date and Time Other Notes: Form COVID-19 State RFR v1 Created 3/05/2020