MEMBER DOCUMENTS

Healthcare Coalition Expenditure Request

Name of Entity Requesting Funding:

Contact Person for this purchase:

Title:

Email:

Phone:

Total amount of Expenditure Request:

Price quote(s) obtained within past 60 days attached. Meets State Expenditure Rules including three quotes or sole source vendor justification letter.

1. Provide a detailed description of item(s) and quantity requested for purchase:

Attach any supporting documentation.

2. Explain how the expenditure fits into the maintenance or expansion of a current or previous project, include the cost of the entire project outlined by funding source(s) and funding year. (Sustainable)

3. Describe how the purchase requested in box #1 above will enhance the region’s capability/capacity to prepare or respond to an emergency. Include a copy of any recent After-Action-Report (AAR) or Corrective Action Plan (CAP) from a real-life event or exercise, Gap Analysis or HVA that identified the preparedness gap.

4. Describe the role that the entity/hospital fulfills in the regional emergency and disaster response plan and how this purchase will enhance the entity/hospital’s ability to contribute to the overall regional response:

File

Max. file size: 70 MB.