PPE Allocation Form
The Humboldt County Emergency Operations Center is reviewing all received resource requests, especially the high demand for PPE. Please answer the questions below so we can assess the need and what we have available to allocate. We will then follow up with all requestors with what we are able to provide.

Completing this form does not guarantee fulfillment of every order that meets our priority criteria nor does it ensure fulfillment of complete orders. Orders may be partially filled due to limited stock. The EOC has the ability to modify our criteria based on emerging response needs.
Organization/Agency *
Point of Contact *
Phone Number *
Email Address *
Resources requested (in order of priority) *
Facility size/Number of beds (if not applicable, enter NA) *
Number of healthcare workers/first responders that will have direct contact with confirmed or suspected cases *
Number of confirmed or suspected cases at your facility (if not applicable, enter NA) *
Number of patients assessed or needing to be assessed per day for COVID-19 (if not applicable, enter NA) *
Number of necessary PPE changes per day, per healthcare worker/first responder (based on most current CDC guidance for PPE preservation https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html ) *
Based on CDC guidance for optimizing PPE, when do you anticipate to run out of the requested resources? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy