York County EMA COVID-19 PPE Request
Sign in to Google to save your progress. Learn more
For all swab/media requests: Does your facility currently have a licensed medical provider (MD, DO, NP) who can order the COVID-19 test? If no, contact your facilities medical control for further guidance
Clear selection
For all swab/media requests: Does your facility currently have a licensed provider (MD, DO, NP, RN, PA, MA) who can collect the samples? If no, please contact your facilities medical control for further guidance.
Clear selection
For all swab/media requests: Does your facility currently have an agreement with a commercial lab to send the samples to for analysis? If no, please contact your nearest diagnostic lab to create an account or to inquire if they can analyze COVID-19 samples.
Clear selection
Are the samples being "self collected”? (Self collection is when the patient obtains the sample themselves with or without the supervision of a medical provider)   *
(For tracking purposes only) Is this swab/VTM request in support of a Maine DHHS approved “Swab and Send” COVID-19 Testing Site?   *
Nasopharyngeal (NP) swabs  (boxes of 100)
Viral transport media (boxes of 72)
Your Name and Title *
Agency Name *
Telephone Number
Email Address *
Agency Type *
*Long Term Care/Home Health Only: Do you have other sources for PPE?
Clear selection
N95 Masks
Number <10
10-50
50-100
100-150
150-200
Extra Small
Small
Universal
Clear selection
Surgical Masks   Size: Universal
Clear selection
Face Shield, Size Universal
Suit, Disposable Protective
1-10
10-25
25-50
50-75
75-100
100-150
150-200
Medium
Large
2 XL
3XL
4 XL
Clear selection
Gloves, Nitrile Medical (in pairs)
1-25
25-50
50-100
100-150
150-200
200-250
250-300
300-350
350-400
400-450
450-500
Small
Medium
Large
X-Large
Clear selection
Gowns
1-10
10-25
25-50
50-75
75-100
100-150
150-200
Large
Extra Large
2 XL
Clear selection
Other Needs
Delivery Location
Only York County locations will be accepted.
Street *
City/Town *
Does the requesting agency/facility have an active Respiratory Protection Program (RPP) in place?
Clear selection
Has Fit Testing been conducted at this agency/facility within the 12 months prior to the date of this request?
Clear selection
To which brand and model N95 have your employees been fit tested to?
Has the requesting agency/facility exhausted on-hand resources?
Clear selection
For EMS, has your agency complete the Maine EMS PPE survey at  https://forms.gle/bUEPxegEScVZ3y6i8   
Clear selection
For hospitals, has your agency submitted your weekly inventory to EMResource?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms