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Maine Dental Association PPE Donation Tracking
Please complete this form to help the MDA track the Personal Protective Equipment that is donated to health care workers and first responders during COVID-19. Thank you!
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* Indicates required question
Your Name:
*
Your answer
Practice Name (if different)
Your answer
I donated the following:
*
Masks N95
Masks (other)
Gloves
Eye protection
Gowns
Hand Sanitizer
Bleach Wipes/ Disinfectant Wipes
Other:
Required
Please specify the quantity of PPE donated:
Your answer
I sent donations to the following location(s):
*
Hospital
Health Clinics including Federally Qualified Health Centers
Nursing Home
First Responders
Other:
I need help coordinating donation drop off:
*
Yes
No
Any additional comments:
Your answer
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