Northern Ontario #PPEforHCP - Donor Form
This is a call out to any industry, business or individuals to donate important personal protective equipment (PPE) and other materials to help our front-line workers in their dedication to patients during this COVID-19 pandemic. All donations will be made locally; this is a chance to help your neighbours, family, and friends during this bizarre and unique time. To make a monetary donation, please visit our GoFundMe page at gf.me/u/xs7f6r

The campaign is led by Northern Ontario School of Medicine (NOSM) students, in close collaboration with the the Ontario Medical Association (OMA) and the North-Regional PPE and Critical Supply Table.

The process:
1. Local clinics, hospitals, physicians and other tell us what they need to keep themselves and patients safe
2. A volunteer uses that information to contact potential donors in the region OR references donors who have come forward by hearing about the Campaign.
3. You, the donor, fills in this form to help us arrange getting the right PPE and equipment to the right place
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.

Email address *
Name and contact information
Address and business name (if applicable)
Where are you located (city in Northern Ontario)?
Do you have any of the following items that can be donated to front-line healthcare workers?
0-50
50-100
100-250
250-500
500+
N95 masks
Construction N95 masks
Surgical masks
Sewn face masks
Sewn caps
Sewn gowns
Other type of mask (please specify in next question)
Disposable gloves
Disposable boot covers
Disposable gowns
Safety glasses/goggles
Face shields (3D printed or laser-cut)
Sanitizer, disinfectant, rubbing alcohol
Baby monitors
Thermometer
Please provide MODEL NUMBERS if applicable and specific QUANTITIES for counting purposes.
Do you have any other items not listed for donation, or that you think may help in COVID-19 relief?
Do you want to make PPE by 3D printing or laser cutting? (Must have access to printer)
Clear selection
Do you want to sew PPE?
Clear selection
Contact for drop-off and pick-up, if different from person completing this form.
Consent for publication of donation *
A copy of your responses will be emailed to the address you provided.
Submit
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