Inspection
**It is assumed that if you are entering a request you will be running out of PPE within the next 14 days. **
1.First Name of Primary Point of Contact
2.Last Name of Primary Point of Contact
3.Facility Name
- 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
7.State
8. ZIP Code
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?
Would you like to place an order for SURGICAL MASKS?
Would you like to place an order for CLOTH FACE COVERINGS?
Would you like to place an order for TYVEK COVERALLS?
Would you like to place an order for FULL FACE SHIELDS?
Would you like to place an order for SURGICAL HOODS?
Would you like to place an order for GLOVES?
Would you like to place an order for BOOT COVERS?
Would you like to place an order for GOGGLES?
Would you like to place an order for IMPERMEABLE GOWNS?
Would you like to place an order for IMPERMEABLE APRONS?
Would you like to place an order for SURGICAL GOWNS?
Would you like to place an order for COVID-19 TEST KITS?
Would you like to place an order for HAND SANITIZER?
Would you like to place an order for any other item?
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.
- 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).
- 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).
- 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).
- 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).
- 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).
- 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).
- 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