UHS Resource Request

Agency / Organization

Name

Email

Office Phone

Mobile Phone





One of following selection is required (Supplies, Equipment, Transportation, Services)









Detail Description Please provide specifics of the request including but not limited to quantity, manufacturer information, web links, purpose for use, etc.

Describe Resource Provide specifics including but not limited to county, hospital, local agency resource channels. This is required to ensure duplication of efforts does not delay solution(s).