PRI: PPE Supply Kit Request Form
The PPE Relief Initiative is donating individual PPE Supply Kits to healthcare workers in the New York & New Jersey metro area who are involved in any level of care that requires direct contact with COVID-19 patients.
PPE Supply Kits may include: reusable respirators, surgical masks, reusable isolation gowns, face shields, goggles, glasses, surgical caps, shoe covers, hand sanitizer, and ear savers.
To qualify you must:
- Be a healthcare worker (doctors, nurses, social workers, phlebotomists, food service workers, sanitation etc)
- Work in the New York or New Jersey metro area
- Have direct contact with COVID-19 patients
- Be able to provide us with an active employee ID (this information will be kept private and used only for the purposes of identity verification)
We will send you an email to complete our process, please ensure your email address is correct.
Name of Healthcare Facility Affiliation
Please be as specific as possible (ie: "Brooklyn Hospital Center - Downtown Campus"). If you are affiliated with multiple facilities, please list the most recent/frequent one.
What type of healthcare facility are you affiliated with?
Ambulatory Surgical Center
Hospice/Palliative Care Center
Long Term Care Facility
Nursing Home/Assisted Living Facility
Outpatient Ambulatory Clinic
Outpatient Radiology Center
What is your Healthcare Role?
Food Service Worker
Home Health Aide
Social Worker/Case Manager
What department(s) have you worked in during the past TWO weeks?
Regional Medical Floors
Telemetry/Intensive Care Unit
Urgent Care/Emergency Department
How many clinical hours have you worked in the past TWO weeks?
When was your most recent shift?
Are you currently treating patients with COVID-19?
Page 1 of 4
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service