The Johns Hopkins Health System Covid-19 Related Supply Chain Donation Survey

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* 1. If you would like to make a donation, please fill out this form. Print out the completed form and include it in your shipment if you would like an "in-kind" donation receipt. Thank you for your generosity. Please begin by providing your contact information.

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Please describe in detail (including brand name/manufacturer, if available) what you would like to donate to the Johns Hopkins Health System. Please answer in particular the following questions:

General description of item?

Brand and catalog number?

Are the packages open/unopened?

Original purpose of item?

How have the items been stored?

Number of items?

Volume of product on a square foot basis (if known)? If unknown, state so.

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* 3. Are you able to deliver or ship the donation directly to the north side open dock door at JH Consolidated Service Center (CSC), Suite A, 5300 Holabird Avenue, Baltimore, Maryland 21224; ATTN: Covid Donations? Delivery is possible from 8 a.m. until 5 p.m., seven days a week. Contacts for shipper: George Lavdas, +14437660758 (mobile), or Charlene Knoerlein (at CSC), +1-410-491-4335

Yes

No

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* 4. Please provide, as applicable: (1) date of shipment; (2) non-U.S. port of shipment; (3) carrier; (4) anticipated arrival date at the CSC; (5) U.S. port of entry; and (6) shipper tracking number.

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* 5. We strongly prefer (and would appreciate it) if you could deliver the items to the CSC. However, if you cannot, please send George Lavdas an email at glavdas1@jhmi.edu, with the size and nature of the donation, and your location, and we will determine whether we are able to pick it up.

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* 6. Please provide any additional details or information that you feel important for us to know about your donation. Thank you very much!!