North Sound ACH Resource Request Form

Welcome to the North Sound ACH Resource Request Form. As environmental disasters, extreme weather events, pandemics and other unforeseen community event impact our region, we are regionalizing procurement and distribution of resources on behalf of community organizations in the North Sound. This form is updated regularly as our inventory changes. There is a comment section at the end of the form to request items that may not be listed and we will do our best to identify options for your needs. 

Eligibility:
Resources must be used to serve people living in the North Sound region. All requests are welcome but we will prioritize those who are working with underserved communities, providing community-based care coordination, and supporting community resource navigators like CHWs and promotoras.

Review Process:
The ACH team reviews these requests weekly. A member of the ACH team will be in touch to let you know about next steps. 

Please contact team@northsoundach.org or call (888) 438-7330 with any questions. For more information about North Sound ACH, please visit: https://northsoundach.org

Thanks for all you do!


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Organization Name *
Organization Address (street, city, zip code) *
Organization's EIN#
Primary Contact Phone Number *
Primary Contact Name *
Primary Contact Email *
1. PPE REQUEST
Below is a current list of personal protective equipment items that are available: 
  • Adult Cloth Masks (900/box)
  • Child Cloth Masks (500/box)
  • Face Bandanas (60/box)
  • Adult KN95 Masks (500/box)
  • Adult N95 Masks (20/box)
  • Adult Disposable Masks (50/box)
  • Child Disposable Masks (50/box)
  • Disposable Gowns - Size Medium (100/box)
  • Hand Sanitizer - 30 ml bottles (100/box)

How many boxes (900/box) of Adult Cloth Masks do you need?
How many boxes (500/box) of Child Cloth Masks do you need?
How many boxes (60/box) of Face Bandanas do you need?
How many boxes (500/box) of Adult KN95 Masks do you need?
How many boxes (20/box) of Adult N95 Masks do you need?
How many boxes (20/box) of Adult Disposable Masks do you need?
How many boxes (100/box) of Disposable Gowns do you need?
How many boxes (100/box) of small Hand Sanitizer bottles do you need?
2. COMMUNITY CARE KITS - COVID, HYGIENE & FOOD
We have three types of community care kits, please see the description below to help you determine what your needs are. 

COVID Kit
  • Intended to give to community members currently impacted by COVID-19
  • Contains a thermometer, disposable mask, disposable gloves, hand sanitizer, soap and ibuprofen
  • Each kit is individually packaged in a SIZE box
Hygiene Kit
  • Intended to provide to community members impacted by disasters, evacuation orders and/or housing insecurity
  • Contains deodorant, shampoo, soap, toothbrushes, toothpaste, thermometer and ibuprofen.
  • Each kit is individually packaged in SIZE a box
Food Kit
  • Intended to provide to community members impacted by COVID-10, disasters, evacuation orders, housing insecurity and food insecurity.
  • Each food kit contains 18-20 meals and 10-14 snacks, depending on serving size. Contents provides food for 1 adult for approximately 3-5 days.
  • Each kit is individually packaged in a box
How many Hygiene care kits do you estimate needing? 
How many COVID Care Kits do you estimate needing? 
How many Food Care Kits do you estimate needing? 
3. COVID-19 TESTS REQUEST - (8/18/22 Limited supplies)
We currently have a limited supply of COVID at home tests on hand, if you are seeking tests for your staff we encourage you to utilize state and local test resources for individuals. 

Washington State's Say Yes to COVID Test
How many COVID at-home tests do you estimate needing? (Our team will notify you when supplies are back.)
4. NALOXONE KITS & FENTANYL STRIPS
North Sound ACH is participating in Washington State Department of Health's Naloxone Distribution Program and has recently acquired fentanyl test strips. The intention of this program is to get naloxone nasal kits and fentanyl strips into the hands of friends and families of people who are at risk of opioid overdose. These are not intended for organizations to have on hand, but to get out into the community.
How many Naloxone (Narcan) nasal kits do you estimate needing? (each kit contains 2 doses of nasal spray, maximum 10 kits)
How many fentanyl test strips do you estimate needing? (each box contains 100 strips, maximum 2 boxes)
Does your organization need overdose reversal educational materials?
Clear selection
Does your organization need technical assistance or support in overdose response education and training?
Clear selection
Participation in this program requires some reporting. Who will be your organization’s contact for reporting to North Sound ACH about kit distribution?
5. Any comments or questions about additional resources not listed or your resource requests?
Submit
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