Medical_Vendor_Response_Form.docx
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Department of Agriculture Forest Service
About this file
This is a medical vendor response form for the USDA Forest Service Medical Vendor Source List supporting wildland fire operations. The form requires vendors to provide company information including name, mailing address, primary and secondary points of contact with phone and email, Unique Entity Identifier (UEI), and SAM registration status. Vendors must also submit detailed resource information for each Rapid Extraction Module (REMS), Medical Support Trailer (MST), or Medical Support Unit (MSU) they can provide, including resource type, typing classification if applicable, and most critically, static physical addresses for each unit.
The completed form must be submitted to SM.FS.WOAIMSSURGE@usda.gov no later than August 18th at 1400 MDT (note: this deadline differs from the August 20th deadline mentioned in the related Sources Sought notice). The form emphasizes that resource locations submitted will remain static for dispatch planning purposes and includes a certification section requiring an authorized signature, name, title, and date. This form is part of the Forest Service's market research effort to identify qualified vendors capable of providing emergency medical support during wildland fire incidents, with responses potentially informing future Emergency Equipment Rental Agreements (EERAs) during urgent fire response situations.
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Other files
| File | Type | Posted |
|---|---|---|
| Medical Support Trailer (MST)SAMPLE.pdf | ||
| Med Support Unit (Med Mod) SAMPLE.pdf | ||
| REMS SPEC SAMPLE.pdf |
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Text version
Medical Vendor Source List Response Form Please complete the form below to be considered for inclusion on the USDA Forest Service Medical Vendor Source List for REMS, MSTs, and MSUs in support of wildland fire operations. Submit the completed form to: SM.FS.WOAIMSSURGE@usda.gov no later than August 18th at 1400 MDT.
Company Name: Click or tap here to enter text.
Mailing Address: Click or tap here to enter text.
City, State, Zip: Click or tap here to enter text.
Primary Point of Contact Name: Click or tap here to enter text.
Phone: Click or tap here to enter text.
Email: Click or tap here to enter text.
Secondary Point of Contact Name: Click or tap here to enter text.
Phone: Click or tap here to enter text.
Email: Click or tap here to enter text.
Unique Entity Identifier (UEI): Click or tap here to enter text.
SAM Registration Status (Y/N): Choose an item.
Resource Information (add lines, as necessary)
| Resource Type (REMS / MST / MSU) |
| Resource Typing, if applicable |
| Physical Address |
| City |
| State |
| ZIP Code |
Certification: I certify that the above information is complete and accurate. I understand that the resource locations submitted will remain static for dispatch planning purposes.
Authorized Signature:
Name & Title: Click or tap here to enter text.
Date: Click or tap to enter a date.
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