The Provincial Emergency Fleet Request Form

The Provincial Emergency Fleet Request Form

Requestor Information

Requestor Name*

Requestor Email*

Requestor Phone*

Health Authority*

Health Authority that requested the device

Select

Shipping Information

BioMed Contact Name

BioMed Contact Phone

BioMed Contact Email

Site Name*

Shipping Address*

Loading Dock Hours of Operation*

Background Information

Business Justifications*

Select

Description

Please provide more details on why the equipment is needed?

What additional countermeasure has been used prior to requesting additional resources?

Urgency

Urgency of the Request*

Select

Urgency

Please describe the urgency of the request in more details

Approximate timeline when the equipment is needed

Equipment Information

Equipment Type*

Select

Ventilator

Ventilator Type

Select or enter value

Ventilator Usage

Select

Preferred Model

Select

Alternative

Select

Humidifier Model

Select

Quantity

Humidifier

Humidifier Model (separate)

Select

Humidifier Quantity

Physiological Monitor

Physiological Monitor

Select or enter value

Philips Monitor Quantity

GE Monitor Quantity

Oxygen Concentrators

Oxygen Concentrators

Select

Oxygen Concentrators Quantity

High Flow Oxygen

High-Flow Model

Select or enter value

Humidifier Model (High-Flow)

Select

Airvo Quantity

Optiflow Quantity

Respiratory Monitor

Respiratory Model

Select

Respiratory Monitor Quantity

ECMO

ECMO Model

Select

Quantity

Please note, local Biomedical Engineering team is responsible for maintaining and repairing the loan device as per its schedule. All part costs for maintenance are covered by PHSA. Should you require parts, kindly contact us at emergencyfleet@phsa.ca.

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