Application: COVID-19 assistance

In recognition of the global need for PPE and other supplies, some organizations are working to make various PPE donations to medical and health institutions in critical need. In addition to practice name, address, and point of contact phone/email, please list the PPE items needed most - ranking top 3 items (i.e. gloves, hand sanitizer, masks). Certain supplies are expected to be available for donation in the coming week(s) and will be direct shipped as quantities allow. While meeting specific PPE needs cannot be guaranteed as suppliers struggle to balance the needs, we hope this process will facilitate the precurement of needed resources. Thank you for the work you are doing and for your patience.

This application process will close on Friday, April 17th.

Question Title

1. Contact information

Name:

Title:

Email address:

Phone number:

Cancer center/practice name:

Address line 1:

Address line 2:

City:

State:

Zip+4

Question Title

2. Please rank the supplies in order of need with 1 being the highest need for your practice?

Masks

Gowns

Face shields

Alcohol wipes

Lysol spray

Gloves

Bleach cleaner

Other (Describe below)

Question Title

* 1. Contact information

Question Title

* 2. Please rank the supplies in order of need with 1 being the highest need for your practice?

Question Title

* 3. Other from above:

1. Contact information

2. Please rank the supplies in order of need with 1 being the highest need for your practice?

3. Other from above: