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. 

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

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* 2. Point of Contact

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

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

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* 5. We are in need of KN95 masks.  Please enter the amount needed below.  
(Note: These are non-NIOSH certified masks)

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* 6. What is the size of the group requesting KN95 masks for?

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

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

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

Date

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* 10. 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)

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

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