Personal Protective Equipment (PPE) from MCDHH

Request Form for Clear Masks & Hand Sanitizer from MCDHH

Use the form below to request your Personal Protective Equipment (PPE) from MCDHH. Funding for this project was obtained from the CARES Act by the State of Missouri. THIS PROGRAM IS ONLY AVAILABLE TO MISSOURI RESIDENTS.

Answer all questions to ensure your request is complete. We will use the e-mail address listed to contact you if we have further questions about your eligibility or delivery instructions. Available only while supplies last on a first-come, first-serve basis; request form will be unavailable when supplies run out. If you have trouble using this form, contact Emily.Morrison@mcdhh.mo.gov.

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* 1. First Name

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* 2. Last Name

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* 3. Mailing Address (MUST be a Missouri address)

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Email

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* 8. Which of the following best describes you?

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* 9. Do you plan to use these masks yourself or for others who interact with you?

I will wear the mask(s) myself.

I will provide the masks to others I interact with, such as family members or healthcare providers.

Both

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* 10. Is the intended recipient(s) of these masks immunocompromized or otherwise at high-risk for having complications with COVID-19 (i.e. elderly, cancer, other chronic health condition)?

Yes

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* 11. How many clear masks would you like to receive from MCDHH? These are made with see-through materials to allow for lip-reading and non-verbal facial expressions. Please note that MCDHH can only provide up to 5 masks per request at this time.

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* 12. Would you like to receive hand sanitizer along with your masks, if available?

Yes

The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, sexual orientation, national origin, age, veteran status, mental or physical disability, or any other basis prohibited by statute in its programs and activities. Inquiries related to department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed to the Jefferson State Office Building, Director of Civil Rights Compliance and MOA Coordinator (Title VI/Title IX/504/ADA/ADAAA/Age Act/GINA/USDA Title VI), 5th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966; email civilrights@dese.mo.gov