A Million Masks: PPE Needs Assessment
This form is to be used only to request PPE for Frontline Healthcare workers at US Hospitals treating Coronavirus. We prioritize those that work in the ER / ICU, and currently are focusing on NYC, but we are quickly expanding to the major metropolitan areas in the country.

Even if you are not in NYC, you should still submit a request, so that we can get the necessary supplies to you as soon as we will be able to. We will reach to you once we are able.
Your Name *
Your answer
Your e-mail *
Your answer
Your phone number *
Your answer
Name of hospital / institution you are requesting for *
Your answer
Full address of the hospital / institution *
Your answer
Institution Type *
Your Job Title / Affiliation with the Hospital *
Your answer
What equipment will your hospital receive for donation? *
If you need additional items, feel free to enter as other (e.g. gloves, gowns, goggles, COVID-19 testing kits,etc.). It would be extra helpful if you can get us your hospital's approved equipment list so we know what you're legally able to accept. You can send that to sumbul@amillionmasks.org
Required
If you are not the hospital supply administrator, what is the contact information of your hospital supply administrator? *
We can coordinate with hospital supply administrators to facilitate larger bulk orders of masks
Your answer
Who should be the pointperson to coordinate the pickup / shipping of supplies to? *
If it is you, just type "me".
Your answer
Approximately, how many COVID-19 patients is your hospital treating right now? *
Your answer
How full are your ICU beds? *
10% full
100% full
How many doctors & nurses are on your ICU & ER Teams? *
This will allow us to set aside allocations based on headcount
Your answer
How low N95/mask supplies are you? *
If it is you, just type "me".
Anything else we need to know? Questions? Comments?
We can coordinate with hospital supply administrators to facilitate larger bulk orders of masks
Your answer
It would be very helpful if you can share our campaign with the doctors, nurses & healthcare workers at your hospital and ask them to send out our link to their communities: www.amillionmasks.org. They can also tweet at us @a_million_masks. The more attention we get, the better able we will be in securing more shipments of supplies.

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