Healthcare Resource Request

Supply Request for All Healthcare Agencies/Facilities

Healthcare Resource Request

Supply Request for All Healthcare Agencies & Facilities
  • Date Format: MM slash DD slash YYYY
  • :
  • Resources On-Hand and Resources Requested:

    Only fill out information for specific items needed. If you are requesting PPE, please describe your existing PPE stock for each item.
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Quantity
  • Type, quantity, etc.
  • How long will your existing stock last – hours/days? When do you anticipate being out of existing supplies? How long do you anticipate the requested supplies will last moving forward?
  • Allocation Decision-Making Criteria

    Requests will monitored during normal business hours and evaluated based on the following criteria. There are no guarantees on resource availability and/or fulfillment of the request.
  • All PPE Provided Must be Replaced by the Receiving Agency/Facility as the Supplies Become Readily Available