PPE REQUEST FORM

PPE

Region 5 Healthcare Coalition

Personal Protective Equipment Request Form
Please remember we can SUPPLEMENT your PPE not SUSTAIN it. We will do what we can.

* Indicates required field

Facility Requesting *

County *

Name of Person Requesting *

First

Last

Contact Number *

Email Of Person Requesting *

Comments *

LIST EQUIPMENT AND QUANTITIES BEING REQUESTED *

Equipment available:
N95 masks - various makes and models
KN95 Masks
Surgical masks
Isolation gowns - various sizes and makes
Face shields
Gloves
Safety Glasses
Thermometers (No Touch)
Hand Sanitizer
Bleach Wipes

I agree to receiving marketing and promotional materials

SUBMIT

Resource Links

Johns Hopkins University of Medicine Coronavirus Resource Center

Centers for Disease Control and Prevention COVID-19

Michigan.gov Coronavirus

PPE

Region 5 Healthcare Coalition

Personal Protective Equipment Request FormPlease remember we can SUPPLEMENT your PPE not SUSTAIN it. We will do what we can.​

5TH DISTRICT MEDICAL RESPONSE COALITION

Personal Protective Equipment Request Form
Please remember we can SUPPLEMENT your PPE not SUSTAIN it. We will do what we can.