Request for PPE Donations

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Please double check your answers for errors!

We will do our best to check in with you regularly as your needs may shift during this crisis. Our goal is to keep our database of needs as up-to-date as possible to ensure the best coverage we can provide.

Note: Please add hospital and medical center addresses, or specific volunteer organization information, and with clear drop-off instructions for our volunteers.

Email *

Which organization do you work for? *

Hospital

Volunteer Group

Your Hospital, Clinic or Organization Name *

Address *

What do you need? *

N-95 Masks

KN95 Masks

Surgical Masks

Procedural Masks

Cloth Masks *Recommended for volunteer/non-medical use

Surgical Gowns

Protective Suits (fluid resistant)

Head Covers (bouffants, surgical caps, etc.)

Gloves (nitrile, non-latex, or latex)

Face Shields

Hand Sanitizer

Medical Coveralls

Disinfectant Wipes

Safety Goggles

Shoe Covers (disposable booties)

Advanced Respirators (PAPR, CAPR, etc)

Other:

Required

Will you take opened packages of unused supplies? *

Yes

Is there a "911" item that's completely run out? Are there items about to run out in 2-3 days? Please note both with quantities.

Please provide # of workers and burn rate for the PPE most needed. For example, our 50 workers burn through about 100 KN95 masks in 2 weeks. The more details the more helpful to us in understanding your need.

How will you accept donations? *

Mail

Dropoff

I Can Pickup

Required

Is there a minimum # of donations you'll take at one time? *

No, we'll take all

Other:

How should donation packages be labeled? (eg. PPE Donations, ATTN: John Smith, Head of Anesthesiology) *

Drop-Off Instructions (eg. curbside procedure, loading dock description, who to speak to). Note: We will only take drop-off locations located away from ER or high-activity locations due to safety of our volunteers. Please give an idea of traffic activity at the dropoff point.

Mailing Instructions (if available)

Will anyone in the hospital be able to pick up donations from another location? If so, please mark what mile radius around the hospital this can happen

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