PPE Emergency Supply Request Form

In order for the most efficient and beneficial dispersal of limited PPE supplies, we are requesting agencies complete this PPE Emergency Supply Request Form in precautions related to COVID-19 in the region. Please take a few moments and complete this request for your agency's current PPE supply need. Please consider this request as an immediate, emergency need and not building a reserve supply.

State and regional resources will not immediately be able to meet all of the requests for all agencies. Keep in mind the region's needs as a whole so that resources can be distributed based on areas of greatest need and maximum impact. Your participation will accurately identify critical supply needs.

As soon as possible, as supplies are received, we will use this information to distribute the resources we receive.

Please do not request supplies if you do not have an emergency need to operate. The form will not permit submission if you have 100 or more items on hand, and will not accept requests of more than 100 of any item. We cannot guarantee the availability of the requested items.

Agency Contact Name:*
Agency License Number:*
I am authorized by my agency to complete this survey on behalf of the organization, and have secured appropriate approval. *
# of units staffed at peak hours*
Average # of calls per unit in 24 hours*
# of N95 masks on hand (including those on units)*
# of N95 masks requested
# of surgical masks on hand (including those on units):*
# of surgical masks requested
# of disposable isolation gowns on hand (all sizes, including those on units)*
# of LARGE gowns requested:
# of X-LARGE gowns requested*
# of XX-LARGE gowns requested
# of face shields on hand (including those on units):*
# of face shields requested:
# of boxes of gloves on hand:*
# of SMALL gloves requested:
# of MEDIUM gloves requested:*
# of LARGE gloves requested:
# of X-LARGE gloves requested:
TYCHEM Coverall*

I understand that this request does not guarantee that I will receive the amount requested. Supplies will be distributed based on a variety of factors, including potential risk for exposure, critical need, and supply availability. We will make every effort to distribute emergency supplies equitably. There is a national shortage of personal protective equipment. We recommend reviewing our website for CDC recommendations on extended use of PPE and alternatives considerations in crisis


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