ADEM Request for Assistance Click here for a print-friendly version of this form Name of Person Requesting: Organization/Agency: Contact 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?