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* 1. Facility Name

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* 2. Facility Type

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* 3. Contact Person

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* 4. Are you experiencing any PPE Supply Chain Disruptions? (Yes/No)

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* 5. If yes, what items are you having issues ordering, obtaining, or keeping in stock at your facility due to vendor/manufacturer shortages (i.e., N95s, Isolation Gowns: Nonsterile, Face Shields, Protective Glasses, Exam Gloves, Particulate Respirators, Hand Sanitizer, Sani-Cloth Wipes, Surgical Masks, etc.)?

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* 6. If yes, what are vendors and/or manufacturers specifically telling you?

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* 7. Are you receiving a smaller allocation of your order or no PPE at all?

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* 8. If you are getting a smaller allocation of your order, is it a smaller allocation of your normal historical orders that you usually receive from that vendor?

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* 9. What vendors do you use? List up to three.

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* 10. Are you seeing a significant increase of PPE use among staff (e.g. beyond the normal amount for flu season)?

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* 11. Do you have an internal PPE allocation or conservation plan?

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* 12. If yes, have you had to start utilizing your PPE plan due to the current situation?

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* 13. What quantities of the following PPE items does your facility currently have on hand?

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* 14. Please provide us with any other comments, issues, or concerns you have regarding your PPE supply.

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