PPE Request Form

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PPE Request Form - Q1 2021

The New York State Coalition Against Sexual Assault is pleased to be able to provide a limited amount of PPE to our member programs.

Available items include:
- Face masks of various types (surgical style 3-ply mask, KN95 masks, and cloth 2-ply masks)
- Hand sanitizer (16oz and 2oz bottles)
- Disinfectant wipes (large canister of 100 wipes and small packs of 50 wipes)
- Disposable gloves (vinyl gloves and nitrile gloves)
- No-contact infrared digital thermometers

If you have questions, please feel free to contact us by email (info@nyscasa.org) with "PPE Request Form" in the subject line.

Please submit requests by March 15, 2021. We may not be able to fulfill requests received after this date.

Email *

Masks

Please indicate the number of items you would like to request. If you do not need a specific item, please list 0 or n/a.

Surgical Style 3-Ply Protective Mask (Please note: Programs may request a maximum quantity of 800 of this item.)

KN95 Face Mask (Please note: Programs may request a maximum quantity of 100 of this item.)

Cloth 2-Ply Face Mask (Please note: Programs may request a maximum quantity of 5 of this item.)

Sanitizer and Disinfectant Wipes

Please indicate the number of items you would like to request. If you do not need a specific item, please list 0 or n/a.

Hand Sanitizer Pump 70% Alcohol - 16 oz. bottle (Please note: Programs may request a maximum quantity of 10 of this item.)

Hand Sanitizer 70% Alcohol - 2 oz. bottle (Please note: Programs may request a maximum quantity of 5 of this item.)

Disinfectant Wipes 70% Alcohol - Canister, 100 wipes per canister (Please note: Programs may request a maximum quantity of 5 of this item.)

Disinfectant Wipes 75% Alcohol - Pack, 50 wipes per pack (Please note: Programs may request a maximum quantity of 5 of this item.)

Gloves

Please indicate the number of items you would like to request. If you do not need a specific item, please list 0 or n/a.

Disposable Vinyl Gloves - Box, 100 gloves per box (Please note: Programs may request a maximum quantity of 3 of this item.)

Disposable Nitrile Gloves - Box, 100 gloves per box (Please note: Programs may request a maximum quantity of 1 of this item.)

Thermometers

Please indicate the number of items you would like to request. If you do not need a specific item, please list 0 or n/a.

Non-contact Infrared Digital Thermometer (Please note: Programs may request a maximum quantity of 1 of this item.)

Please click "Next" to provide information about your program, including your program's mailing address and the name and email of the program director/primary contact.

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