MDHHS CHILD KN95 Mask Distribution Survey

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* 1. Local Health Department:

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* 2. Point of Contact

Name

Email Address

Phone Number

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* 3. Shipping Address

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 4. Is there a loading dock at this shipping location?

Yes

No

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* 5. Number of CHILD KN95 masks requested:

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* 6. Additional thoughts on distribution strategies: