PPE Inventory and Needs Survey

Please Read:

The MN Department of Health and the EMSRB are collecting data on PPE inventories and needs during the COVID response. Please complete this form to help us understand the needs of our ambulance services. Please note, this is NOT a guarantee of receipt of additional PPE but it will help us prioritize disbursements as supplies become available.

Question Title

* 1. Please provide the following information:

Name:

Ambulance Service:

Region:

Phone Number:

Email:

Has your county been affected?

Question Title

* 2. Please report what you have ON HAND for the following PPE. Please report the total number on hand for masks, gowns, and face shields. Please report the number of boxes and sizes for gloves: (Numerical Data Only)

N95 masks:

Surgical masks:

Gowns:

Face Shields/Eye protection:

Gloves (Total Boxes):

Question Title

* 3. To be eligible for distribution of PPE, an ambulance service must have attempted to order the requested items and the order declined or placed on back-order.

Please upload a copy of your PPE order and denial.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 4. What are your immediate needs with regard to the following PPE: (Numerical Data Only)

N95 masks:

Surgical masks:

Gowns:

Face Shields/Eye Protection:

Gloves (Total Boxes):