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Personal Protective Equipment (PPE) Request Form

1.Introduction & Attestation

Please use the form below to request various PPE items available.

We are only distributing adult-sized PPE items. We do not have child-sized PPE in stock currently.

Confirmed orders will receive an email from us. Shipments are sent out once a week but can take up to 2 weeks for delivery and are dependent on available inventory. We are unable to accommodate requests for specific delivery dates, times, or other instructions.
Attestation

I understand this is an agreement between the Organization and DPH. To receive Personal Protective Equipment (PPE) supplies at no cost for use by the community in which it is located, the Organization agrees that it will adhere to the following requirements:

  1. The Organization must not sell or seek reimbursement for the PPE supplies provided at no cost to the Organization for this or any previous requests.
  2. The Organization must provide the PPE regardless of the recipient's ability to pay administration or related fees or coverage status. The Organization may not seek, and will have never sought, any reimbursement from the PPE recipient, including through balance billing.
  3. The Organization must have processes to ensure timely and proper acceptance of PPE supplies. Those processes must include, but are not limited to, procedures for accepting delivery through commercial delivery services.
1.I attest that the Organization will agree to the above statements to be eligible for free PPE under DPH's distribution program.(Required.)
2.Enter the first and last name of the signer below, which will act as an e-signature affirming your attestation on behalf of the Organization.(Required.)