MAY UPDATE: PPE Needs Survey

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* 1. Agency Name

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* 2. Contact Name

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* 3. Email Address

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* 4. Mailing Address to Receive PPE Shipment

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* 5. Number of Consumers/Patients (Average Daily Census)

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* 6. Please quantify your need for each type of PPE.

N95 Masks

KN95 Masks

Surgical Masks

Cloth or Similar Masks

Gowns

Gloves (small) (box of 100)

Gloves (medium) (box of 100)

Gloves (large) (box of 100)

Hand Sanitizer (4 oz. bottle)

Thermometers