Healthcare Provider Need Survey

Overview: This form is part of a collaborative site between several federal, state, and local New Mexico entities intended to connect New Mexico medical providers with solutions and capabilities from across the State. It is not intended to address individual medical needs. If you are in need of immediate medical attention or help, please call 911 or refer to other communication avenues as publicized by local, State or Federal entities.

***NOTICE***

If you are a medical provider with immediate personal protective equipment (PPE) or medical supply needs, please contact your county, city, or tribal emergency manager who is working directly with the State to fulfill requests as quickly as possible.

Question Title

* 1. Are you the person responsible for the acquisition of PPE (or responding on behalf of the person who is responsible)?

Question Title

* 2. Point of Contact

Name

Organization Name

Job Title

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Please select the New Mexico county/tribal government area where your institution is located.

Question Title

* 4. Please select all that apply to your organization's efforts.

We are actively treating COVID-19 positive patients

We are actively working with COVID-19 positive patients

We are working in a nursing home/assisted living care center

We are working in a funeral home/crematory

We are not actively treating and/or working with COVID positive patients, but are at high risk

Question Title

* 5. We are in need of the following supplies and/or equipment. [Select all that apply]

Note: Any additional detail related to items may be noted in the Comments/Notes field or uploaded through the Attachment field.

K-N95 Masks

Other (please specify)

Question Title

* 6. Please note in the space below any supplies, materials, and/or equipment that you would consider a "critical need" for your institution.

Question Title

* 7. What is the size of the group requesting PPE (# of employees that need PPE?)

Question Title

* 8. We have the ability to procure these items, if required by the supplier/distributor/manufacturer.

Question Title

* 9. We have the ability to pick-up and transport supplies/equipment from an individual, organization or supplier/distributor

Question Title

* 10. If available, we will need these supplies and/or equipment by the following date:

Date

Question Title

* 11. Comments/Notes: (please consider using this space or the Attachment field below to provide any specific information that would help us better understand your needs, include quantities, sizes, specifications)

Question Title

* 12. Attachments - Use the file upload button below to provide further information related to your response.

File size limit is 16MB (Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported)

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

Choose File

Healthcare Provider Need Survey

Question Title

* 1. Are you the person responsible for the acquisition of PPE (or responding on behalf of the person who is responsible)?

Question Title

* 2. Point of Contact

Question Title

* 3. Please select the New Mexico county/tribal government area where your institution is located.

Question Title

* 4. Please select all that apply to your organization's efforts.

Question Title

* 5. We are in need of the following supplies and/or equipment. [Select all that apply] Note: Any additional detail related to items may be noted in the Comments/Notes field or uploaded through the Attachment field.

Question Title

* 6. Please note in the space below any supplies, materials, and/or equipment that you would consider a "critical need" for your institution.

Question Title

* 7. What is the size of the group requesting PPE (# of employees that need PPE?)

Question Title

* 8. We have the ability to procure these items, if required by the supplier/distributor/manufacturer.

Question Title

* 9. We have the ability to pick-up and transport supplies/equipment from an individual, organization or supplier/distributor

Question Title

* 10. If available, we will need these supplies and/or equipment by the following date:

Question Title

* 11. Comments/Notes: (please consider using this space or the Attachment field below to provide any specific information that would help us better understand your needs, include quantities, sizes, specifications)

Question Title

* 12. Attachments - Use the file upload button below to provide further information related to your response.

* 5. We are in need of the following supplies and/or equipment. [Select all that apply]

Note: Any additional detail related to items may be noted in the Comments/Notes field or uploaded through the Attachment field.