ADEM Request for Assistance

 Do not submit more than one item per request.

* Denotes a required field Hyperlink to  a printer-friendly version of this form

Name of Person Requesting: *
Organization/Agency: *
Contact Phone Number: *
Has Chief Elected Official formally declared a state of emergency to ADEM?  No     Yes
Is this an aviation request?  No     Yes       If yes, indicate purpose
DETAILED RESOURCE CHARACTERISTICS

Specific Resource Requested:

Does requestor have ability to pick up the resource if within a reasonable distance?  No     Yes

Transportation required?

Where is resource to be delivered or report?

Name, Title, Agency and Phone number of  person to receive resource?

How long is resource needed? 

Needed supporting equipment, Fuel, Water Etc:

Personnel required to operate/support:


Comments & Notes:
INFORMATION NEEDED FOR SPECIFIC TYPES OF RESOURCES
Drinking Water
How many persons need drinking water?       
How many days will they need to be supplied with drinking water? 
If water tankers are provided does requestor have suitable means of distribution?  No     Yes
If bottled water is provided does requestor have a loading dock necessary equipment to offload pallets? No     Yes
Food
How many persons need food? 
How many days will they need to be supplied with food? 
How many meals per day per person will be served?       
Are facilities and personnel available to prepare hot meals? No     Yes
Generators
What type of facility requires a generator? 
What size generator is needed (size in Kilowatts or Kilovolt amps)  
What voltage? 
What phase?   
Can the requestor refuel generator?.    No     Yes   If yes, can requestor provide: Gas Diesel 
Does requestor have trained/qualified personnel to maintain the generator? No     Yes
Does requestor have licensed master electrician to hook up generator? No     Yes
Does requestor have equipment to off-load generator if necessary? No     Yes
Is facility equipped for quick connect to the generator.  No     Yes
 
Pumps
What is necessary pipe diameter or volume of water in gallons per minute? 
Does the water being pumped contain debris? No     Yes
What is necessary pipe length in feet?   
Can the requestor refuel pump?.     No     Yes   If yes, can requestor provide:  Gas Diesel 
Does requestor have trained/qualified personnel to maintain the pump?No     Yes
Does requestor have equipment to off-load pump if necessary?No     Yes
Vehicles
If a truck is needed, what size truck (volume/tonnage)?  
Are qualified/licensed drivers available?  No     Yes
Does truck require four-wheel drive capability? No     Yes
What type of fuel is preferred? Gas Diesel 
Sandbags
Does requestor have the fill material for sandbags? No     Yes
Does requestor have the labor force to fill sandbags? No     Yes
Does requestor have the equipment to fill sandbags? No     Yes
Shelter
How many persons need shelter?        
How many days will they need to be supplied with shelter?