DHHS PPE Request Form – COVID 19

Facility Name*
Facility Type*
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 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
- Disinfectant Spray
- Cloth Masks
- Face Shields
- Gloves
- Goggles
- Gowns
- Hand Sanitizer - One Gallon or 8oz bottles
- N95 Masks
- Surgical Masks
- Thermometers
- Body Bags
PPE Materials Requested - School Nurse*
- Disinfectant Wipes
- Cloth Masks
- Face Shields
- Gloves
- Goggles
- Gowns
- Hand Sanitizer - 1 Gallon or 8oz bottles
- N95 Masks
- Surgical Masks
- Thermometers
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 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 packs of disinfectant wipes your facility is requesting
(180 wipes per pack)
Disinfectant Spray
Disinfectant Spray - 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 Spray - 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 Spray - Requested Amount*
Please enter a number greater than or equal to 1.
Indicate the number of containers of disinfectant spray your facility is requesting
(Container Size: 1 qt)
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 individual 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
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*
Please enter a number greater than or equal to 1.
Indicate the number of goggles your facility is requesting
Gowns
Gown sizes requested*
- Large
- XL
- XXL - UNAVAILABLE
- Universal
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*
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
(100 gowns per box)
XL Gowns*
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
(100 gowns per box)
XXL Gowns - Current Inventory - OUT OF STOCK*
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 individual universal gowns your facility is requesting
(15 gowns per pack; 75 packs per case)
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 (indicate individual number)
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
(100 gloves per box)
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
(100 gloves per box)
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
(100 gloves per box)
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
(100 gloves per box)
XXL Gloves - Current Inventory - OUT OF STOCK*
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*
Indicate the current amount of hand sanitizer your facility has.
Unit*
Hand Sanitizer - Daily Burn Rate*
Indicate the amount of hand sanitizer your facility goes through each day.
Unit*
Hand Sanitizer - Requested Amount*
Please enter a number greater than or equal to 1.
Indicate the number of gallons or bottles of hand sanitizer your facility is requesting - NOTE** The default Hand Sanitizer comes in one gallon jugs. Please indicate in the Notes section if you want 8 oz bottles instead.
Unit*
N95 Masks
N95 Masks - Current Inventory*
Please enter a number greater than or equal to 1.
Indicate the current amount of N95 masks your facility has.
N95 Masks - Daily Burn Rate*
Please enter a number greater than or equal to 1.
Indicate the number of N95 masks your facility goes through each day.
N95 Masks - Requested Amount*
Please enter a number greater than or equal to 1.
Indicate the number of individual N95 masks your facility is requesting
N95 Masks: Honeywell DC300N95, Makrite 9500 SMALL ONLY sizes; and 3M 1870
KN95 Masks: OUT OF STOCK
*Indicate in the Notes what brand/model you are asking for*
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 individual 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