SOMA NJ Face Shield Request Form for HCPs and First Responders

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PLEASE READ BEFORE PROCEEDING TO THE FORM. THANKS!

SOMA NJ 3D PRINTERS' ALLIANCE is a volunteer network that makes face shields for HCPs and first responders in the New Jersey region. Find out more about us and what we make at https://www.somanj3dpa.org/. CONTACT US at somanj3Dpa@gmail.com https://www.facebook.com/SOMANJ3DPrintersAlliance

YOUR PRIVACY: The information below will be shared among our volunteers but will not be posted publicly on the FB group with the exception of the name of the facility. **If you need the name of the destination/facility to remain private, please write "Private" in that field and then note the name of the facility in Comments at end.**

DISCLAIMER: These items are provided in good faith as an emergency supply for use during a product shortage. These items have not been evaluated for use by any regulatory agency beyond NIH review as stated below. Please use discretion when using these items and only use if no other solution is available. Products are not FDA cleared or approved, but are authorized by FDA under an EUA for use by healthcare providers as personal protective equipment. Products are only authorized for the duration of the declaration that circumstances justifying the authorization of emergency use under Section 564(b)(1) of the Act, 21 USC 360bbb-3(b)(1) unless the authorization is terminated or revoked sooner.

Email *

[If you are a SOMA volunteer making this request on behalf of a contact, please enter your name here. If you are a member of the public who received this form directly from a SOMA volunteer, please note that volunteer's name here.]

First and Last Name: *

Please choose which best describes your need/use: *

Hospital HCP

PD/FD/EMT

Other HCP

Other:

Phone Number *

Preferred method of contact: *

Phone

Facebook Messenger

Destination - Institution and Department/Unit *

Destination - City, State *

Destination - ZIP *

How many shields do you need? (note that they are reusable by a single user) *

Shield design: Each shield consists of a re-usable plastic visor (PETG or PLA) with replaceable 8.5 x 11" transparent shield (replace with any transparency sheet or clear binder cover). Per NIH, the Budmen and Verkstan designs have "undergone review in a clinical setting and are recommended when fabricated as instructed." Budmen: https://3dprint.nih.gov/discover/3dpx-013309. Verkstan: https://3dprint.nih.gov/discover/3dpx-013306. **We will try to fill each order with a single design unless otherwise requested.** *

Budmen

3DVerkstan

Budmen or 3DVerkstan (select for fastest service)

Optional - number of Ear Savers needed? (These are for hooking elastic mask straps onto at back of head. We make several styles; here is one https://3dprint.nih.gov/discover/3DPX-013410)

Please use this space to note: --any comments or questions; --drop off address if different from destination facility address; --if you are able to drive to pick up, how far (eg "can drive up to 1 hr")

Thank you! We will contact you when your order is ready.

QUESTIONS? m.me/SOMANJ3DPrintersAlliance OR somanj3Dpa@gmail.com.
CURIOUS? https://www.somanj3dpa.org/ AND https://www.facebook.com/SOMANJ3DPrintersAlliance
$$ DONATIONS? To support cost of materials go to https://www.gofundme.com/f/face-shields-for-nj-healthcare-workers. **Donating funds is not required and is not connected to your request in any way**

A copy of your responses will be emailed to the address you provided.

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