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DHHS PPE Request Form – COVID 19
Facility Name
*
Facility Type
*
--SELECT ONE--
Corrections
Dental Office
Doctor's Office
Eye Doctor
First Responder
Funeral Home
Hospital
Long Term Care
Mental Health
Substance Abuse
Urgent Care
Other
Please describe the type of facility
*
Number of Employees
*
Number of patients served per day
*
This could be a facility census or how many patients are seen per day.
I certify the above facility is a municipal organization or provides medical services.
*
Yes
Facility Address
*
No PO Boxes, please
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Requestor Name
*
First
Last
Requestor Email
*
Enter Email
Confirm Email
Primary Phone Number
*
Ensure this is a number you can be reached both during the day and after hours/weekends
Alternate Phone
Secondary email
Enter Email
Confirm Email
PPE Materials Requested
*
Disinfectant Wipes - UNAVAILABLE
Cloth Masks
Face Shields
Gloves
Goggles - UNAVAILABLE
Gowns - ONLY XL and XXL
Hand Sanitizer - UNAVAILABLE
N95/KN95 Masks
Surgical Masks
Thermometers
Body Bags
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body bags are not available at this time.
Body Bags
Body Bags - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of body bags your facility has.
Body Bags - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of body bags your facility goes through each day.
Body Bags - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of containers of body bags your facility is requesting
Disinfectant Wipes
Disinfectant Wipes - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of containers of disinfectant wipes your facility has.
Disinfectant Wipes - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of containers of disinfectant wipes your facility goes through each day.
Disinfectant Wipes - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of containers of disinfectant wipes your facility is requesting
Cloth Masks
Cloth Masks - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of cloth masks your facility has.
Cloth Masks - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of cloth masks your facility goes through each day.
Cloth Masks - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of cloth masks your facility is requesting
Face Shields
Face Shields - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of face shields your facility has.
Face Shields - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of face shields your facility goes through each day.
Face Shields - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of face shields your facility is requesting
Goggles - CURRENTLY OUT OF STOCK
Goggles - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of goggles your facility has.
Goggles - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of goggles your facility goes through each day.
Goggles - Requested Amount - UNAVAILABLE
*
Please enter a number greater than or equal to
1
.
Indicate the number of goggles your facility is requesting
Gowns
Gown sizes requested
*
Medium - UNAVAILABLE
Large - UNAVAILABLE
XL
XXL
Universal (Limited Quantities)
Medium Gowns - Current Inventory - OUT OF STOCK
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of medium gowns your facility has.
Medium Gowns - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of medium gowns your facility goes through each day.
Medium Gowns - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of medium gowns your facility is requesting
Large Gowns - Current Inventory - OUT OF STOCK
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of large gowns your facility has.
Large Gowns - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of large gowns your facility goes through each day.
Large Gowns - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of large gowns your facility is requesting
XL Gowns - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of XL gowns your facility has.
XL Gowns - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of XL gowns your facility goes through each day.
XL Gowns - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of XL gowns your facility is requesting
XXL Gowns - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of XXL gowns your facility has.
XXL Gowns - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of XXL gowns your facility goes through each day.
XXL Gowns - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of XXL gowns your facility is requesting
Universal Gowns - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of universal gowns your facility has.
Universal Gowns - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of universal gowns your facility goes through each day.
Universal Gowns - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of universal gowns your facility is requesting
Gowns - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of gowns your facility has.
Gowns - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of gowns your facility goes through each day.
Gowns - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of gowns your facility is requesting
Gloves
Glove sizes requested
*
Small
Medium
Large
XL
Small Gloves - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of small gloves your facility has.
Small Gloves - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of small gloves your facility goes through each day.
Small Gloves - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of small gloves your facility is requesting
Medium Gloves - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of medium gloves your facility has.
Medium Gloves - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of medium gloves your facility goes through each day.
Medium Gloves - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of medium gloves your facility is requesting
Large Gloves - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of large gloves your facility has.
Large Gloves - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of large gloves your facility goes through each day.
Large Gloves - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of large gloves your facility is requesting
XL Gloves - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of XL gloves your facility has.
XL Gloves - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of XL gloves your facility goes through each day.
XL Gloves - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of XL gloves your facility is requesting
XXL Gloves - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of XXL gloves your facility has.
XXL Gloves - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of XXL gloves your facility goes through each day.
XXL Gloves - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of XXL gloves your facility is requesting
Hand Sanitizer
Hand Sanitizer - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of hand sanitizer your facility has.
Unit
*
--SELECT ONE--
8 fl oz bottles
12 fl oz bottles
Dispenser pouches
Gallons
Hand Sanitizer - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of hand sanitizer your facility goes through each day.
Hand Sanitizer - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of hand sanitizer your facility is requesting
Unit
*
--SELECT ONE--
8 fl oz bottles
12 fl oz bottles
Dispenser pouches
Gallons
N95/KN95 Masks
N95/KN95 Masks - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of N95/KN95 masks your facility has.
N95/KN95 Masks - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of N95/KN95 masks your facility goes through each day.
N95/KN95 Masks - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of N95/KN95 masks your facility is requesting
Surgical Masks
Surgical Masks - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of surgical masks your facility has.
Surgical Masks - Daily Burn Rate
*
Please enter a number greater than or equal to
1
.
Indicate the number of surgical masks your facility goes through each day.
Surgical Masks - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of surgical masks your facility is requesting
Thermometers
Thermometers - Current Inventory
*
Please enter a number greater than or equal to
1
.
Indicate the current amount of thermometers your facility has.
Thermometers - Requested Amount
*
Please enter a number greater than or equal to
1
.
Indicate the number of thermometers your facility is requesting
Notes
