RE-1 District Provided Mask and PPE ordering form

Question Title

* 1. Please select the type of mask you are requesting from the district (see mask guidance on HR webpage for more information on mask types)

Double layer cotton mask (reusable, district will provide 2 per quarter)

Double layer cotton mask with 'see through' mouth (reusable, district will provide 2 per quarter)

Quilted layer (reusable, district will provide 2 per quarter)

KN95 (disposable following limited number of uses, Governor is providing 1 per week)

I am choosing to provide and wear my own mask

Other (medical procedure mask)

Question Title

* 2. Are you requesting a clear face shield? (these will be available based on employee need and work setting). These do NOT replace a mask and would be worn in addition to a mask

Yes

No

Question Title

* 3. Name

Question Title

* 4. School or department

Question Title

* 5. Role

Question Title

* 6. Any additional comments for HR