COVID-19 PPE Resource Request Form Checklist

**It is assumed that if you are entering a request you will be running out of PPE within the next 14 days. **

Facility Information

1.First Name of Primary Point of Contact

2.Last Name of Primary Point of Contact

3.Facility Name

4.Type of Facility Please select the facility type that BEST describes you. If none match, you may select Other.

Behavioral Health Care
Correctional/Detention Facility
Covid 19 Specialty location (Testing, Temporary Medical)
Dental Facility
First Responder - Emergency Medical Services
First Responder - Public Safety/Law Enforcement
First Responder - Fire Department
Funeral Home
Home Health/Visiting Nurse/Hospice Service
Hospital
Inpatient Psychiatric Care Facilities
Long Term or Short Term Residential Care
Municipality
Primary Care, Community Health Cares, Other Outpatient Care
Shelter for Marginally House Persons (including temporary housing at hotels)
VT Department of Health
Other State agency or department

Specify Other

7.State

8. ZIP Code

9.Specific Delivery Address and Instructions If your delivery address is different, please enter the entire address. If you receive larger shipments at a loading dock, please provide specific instructions.

10. Phone Number Enter digits only. Our drivers make every effort to contact you so please list a phone number where you can be reached during this “stay home, stay safe” period.

11.Fax Number Enter digits only.

12. Email address

Would you like to place an order for N95 FFP RESPIRATORS?

Number of N95 FFP RESPIRATORS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of N95 FFP RESPIRATORS (i.e. how much of this item are you using in one day)

Number of N95 FFP RESPIRATORS Requested (Number of units only)

If you need to specify respirator model, do so here.

Sample Photo if applicable

Would you like to place an order for SURGICAL MASKS?

Number of SURGICAL MASKS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of SURGICAL MASKS (i.e. how much of this item are you using in one day)

Number of SURGICAL MASKS Requested (Number of units only)

Would you like to place an order for CLOTH FACE COVERINGS?

Number of CLOTH FACE COVERINGS Requested (Number of units only)

Would you like to place an order for TYVEK COVERALLS?

Number of TYVEK COVERALLS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of TYVEK COVERALLS (i.e. how much of this item are you using in one day)

Number of TYVEK COVERALLS Requested (Number of units only)

Would you like to place an order for FULL FACE SHIELDS?

Number of FULL FACE SHIELDS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of FULL FACE SHIELDS (i.e. how much of this item are you using in one day)

Number of FULL FACE SHIELDS Requested (Number of units only)

Would you like to place an order for SURGICAL HOODS?

Number of SURGICAL HOODS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of SURGICAL HOODS (i.e. how much of this item are you using in one day)

Number of SURGICAL HOODS Requested (Number of units only)

Would you like to place an order for GLOVES?

Number of GLOVES in your current stock (Please enter the number of individual gloves, NOT PAIRS or BOXES or CASES. For example, if you have 1 box with 20 gloves, enter 20.)

Current burn rate of GLOVES (i.e. how much of this item are you using in one day)

Number of GLOVES Requested (Number of individual gloves only, not pairs)

If you need to specify GLOVE sizes, do so here.

Would you like to place an order for BOOT COVERS?

Number of BOOT COVERS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of BOOT COVERS (i.e. how much of this item are you using in one day)

Number of BOOT COVERS Requested (Number of units only)

Would you like to place an order for GOGGLES?

Number of GOGGLES in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of GOGGLES (i.e. how much of this item are you using in one day)

Number of GOGGLES Requested (Number of units only)

Would you like to place an order for IMPERMEABLE GOWNS?

Number of IMPERMEABLE GOWNS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of IMPERMEABLE GOWNS (i.e. how much of this item are you using in one day)

Number of IMPERMEABLE GOWNS Requested (Number of units only)

Would you like to place an order for IMPERMEABLE APRONS?

Number of IMPERMEABLE APRONS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of IMPERMEABLE APRONS (i.e. how much of this item are you using in one day)

Number of IMPERMEABLE APRONS Requested (Number of units only)

Would you like to place an order for SURGICAL GOWNS?

Number of SURGICAL GOWNS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of SURGICAL GOWNS (i.e. how much of this item are you using in one day)

Number of SURGICAL GOWNS Requested (Number of units only)

Would you like to place an order for COVID-19 TEST KITS?

Number of VDHL COVID-19 TEST KITS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of VDHL COVID-19 TEST KITS (i.e. how much of this item are you using in one day)

Number of COVID-19 TEST KITS Requested (Number of units only)

Would you like to place an order for HAND SANITIZER?

Number of HAND SANITIZER in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate of HAND SANITIZER (i.e. how much of this item are you using in one day)

Number of HAND SANITIZER Requested (Number of units only)

Would you like to place an order for any other item?

Please specify the item What is not on the request form is generally not stocked but if you are needing another item then note it here for trends, putting an item in other does not guarantee delivery.

Number of UNITS in your current stock (Please enter the number of individual units, NOT BOXES or CASES. For example, if you have 1 box with 20 units, enter 20.)

Current burn rate (i.e. how much of this item are you using in one day)

Number of UNITS Requested (Number of units only)

Final Questions

Please use this space to provide additional information about your facility, product needs, or delivery methods that will assist us in completing your order.

Rank the activities for which the COVID-specific resource requests from the previous items will be used in order of frequency of occurrence.

1st

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

2nd

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

3rd

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

4th

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

5th

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

6th

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

7th

Direct contact with surfaces and objects used by a potential COVID-19 patient.
Direct contact with surfaces and objects used by a confirmed COVID-19 patient.
Providing care within 6 feet of a potential COVID-19 patient.
Providing care within 6 feet of a confirmed COVID-19 patient.
Handling laboratory specimens or human remains of a potential COVID-19 patient.
Handling laboratory specimens or human remains of a confirmed COVID-19 patient.
Providing direct patient care to a confirmed COVID-19 patient including Aerosol-Generating Procedures (AGPs).

Please read and acknowledge by selecting the following option:

I understand that all orders are subject to availability constraints. My order will be filled to the extent that supplies allow.

I understand

COVID-19 PPE Resource Request Form Checklist

Free COVID-19 PPE Resource Request Form Checklist

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