Hospital DIY Fabric Masks Request Form
Please provide us information about you and the hospital you work for.

These face masks are generally made with cotton or cotton blend material by volunteer makers.

Masks will be shipped directly to the address you provide.

All masks are washable, please wash them prior to use.

If you have any questions, email us at
Email address *
Phone Number *
Your answer
Your Full Name *
Your answer
Hospital Name *
Your answer
Hospital Location (City, State) *
Your answer
Shipping Name & Address for Masks
Your answer
On a scale of 1-10, how badly do you need face masks? *
I acknowledge homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. Masks should be washed and sanitized prior to use. Masks will be coming from makers around the country and materials and design will vary. *
Shipping address and name will be given to volunteer makers around the country who will be sending masks directly to you. This address will be shared with registered members. *
Never submit passwords through Google Forms.
This form was created inside of Stitchroom. Report Abuse