North Sound ACH Resource Request Form

As the region continues to respond to COVID-19, North Sound ACH is working to regionalize a resource for personal protective equipment and supplies (i.e., cloth and disposable masks, sanitizer and gloves). Our team wants to assure the community organizations have what is needed, especially those who work and live in high-risk exposure settings.

This form lists what we currently have the ability to request from the State and other sponsors. Our intention is that these are used for clients, patients, staff and community members. There are some restrictions on the items we have available:
1) They are not to be sold.
2) No one will be asked to pay you for these products.
3) The items are for your urgent and immediate use.

In addition, we are following WADOH's Prioritization Guidelines for Allocation of Personal Protective Equipment that prioritize facilities based on their exposure risks. The ACH team reviews these requests weekly. A member of the ACH team will be in touch to let you know what we have on hand and to coordinate a time for you to pick-up products if we can provide what you requested. All people present at the time of pick up must wear face coverings and take appropriate precautions to prevent the spread of COVID-19. We are unable to offer delivery at this time.

Please contact team@northsoundach.org with any questions.

For more information about North Sound ACH, please visit: https://northsoundach.org

Thanks for all you do!
Organization Name *
Organization Address (street, city, zip code) *
Primary Contact Name *
Primary Contact Email *
Primary Contact Phone Number *
How many adult cloth masks do you estimate needing? (minimum 900)
How many child cloth masks do you estimate needing? (minimum 500)
How many KN95 disposable masks do you estimate needing? (minimum 500)
How many disposable gowns do you estimate needing? (minimum 100)
How many bottles of small hand sanitizer (30 mL) do you estimate needing? (minimum 100)
Which counties does your organization currently serve? (check all that apply)
Which tribal nations does your organization currently serve? (check all that apply)
Other items or resources that you are in immediate need of? We may not have those items but will work to connect you to resources.
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