Northern Ontario #PPEforHCP - Needs Assessment

IMPORTANT: This form should not be relied on alone for acute care centres or long-term care who are within 14 days or less of PPE/ are in critical need. Please use your supply chain escalation process in addition to this form to ensure that your PPE and equipment needs are met as quickly as possible.

The Northern Ontario PPE for HCP Campaign is a NOSM student-run project that is working collaboratively with the North Regional PPE and Critical Supplies Table, Northern Ontario School of Medicine (NOSM), the Ontario Medical Student Association (OMSA) and the Ontario Medical Association (OMA).

Our goal is to source and manufacture personal protective equipment through donations and get it to communities across all of northern Ontario. We are aiming to fill a gap for rural and isolated communities, and are working with both larger and smaller hospitals and clinics.

The process:
1. By completing this form, you have officially entered into the campaign. The responses to this form will be processed and sent to your regional team, as well as any partners that are helping to source PPE.
2. Teams of students who have been sourcing PPE in the region examine the needs identified and arrange donations.
3. Specific donations are matched to the needs in the region, and if regional donations are not available, shipping donations in from out of region will be explored (dependent on availability).
4. Drop-off and pick-up protocols will be arranged on a case by case basis that emphasizes the safety of donors, recipients, and the public.

For any questions, please contact either Alannah MacLean (northwestern Ontario) alamaclean@nosm.ca or Sarah Mavin (northeastern Ontario) smavin@nosm.ca.

IMPORTANT - Release of Liability
By submitting this survey, you are agreeing to the following:

"I understand the Northern Ontario PPE for HCP campaign, Northern Ontario School of Medicine, the Ontario Medical Association, Local Health Integration Network, Ontario Health and Ministry of Health assumes no liability associated with the use of the Equipment and Supplies being provided to my organization. I understand the Equipment and Supplies are offered ‘as is’ and I assume all responsibility to determine the items are acceptable before use.

I acknowledge I had an opportunity to ask questions about this Campaign and all questions have been answered to my satisfaction. On behalf of my organization I understand and assume the known, obvious and foreseeable physical risks as well as any injury/ harm/loss arising from the use of the Equipment and Supplies and that I submit this form freely."
Email address *
Name and phone
Facility Shipping Address and Purolator number if you have one (Please include name of facility)
Please outline you specific PPE needs. Please note that we are reliant on donations to help bridge your needs. The selection of items does not guarantee that we can source these items, however we will do our best to attract donors accordingly.
Does your requested PPE need to be MEDICAL GRADE? If yes, please specify details such as model numbers and any details on items not listed. (NOTE: the Campaign mostly distributes non-medical grade PPE as we are reliant on donations from other industries)
What are your equipment needs?
We are manufacturing face shields and piloting distribution in Thunder Bay. Would you be interested in receiving this type of face shield? (manufactured in non-MDE licence facility; no cost for shields)
(Optional) Do you have any advice for the team regarding this form or the process?
IMPORTANT - The Campaign is collaborating directly with the OMA, Northern Supply Chain, Findthemasks.com, and other initiatives. As such, you must agree to the following for us to help you to get the most out of every initiative possible. *
Required
IMPORTANT - Release of Liability. By submitting this survey, you must agree to ALL of the following by checking off each statement: *
Required
A copy of your responses will be emailed to the address you provided.
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