Community Shield Request Form
The Community Shield initiative was started by InkSmith in Kitchener, Ontario on March 20th with the help of Dr. Neil Naik, president of the KW Academy of Medicine. The goal was to crowd-source community 3D printers, laser cutters and volunteer labour to create face shields for health care and front line workers. As of April 9th, this initiative is being led by KW's largest makerspace - www.kwartzlab.ca - with the support, material and logistics continuing to be provided by InkSmith.

Please use this form to request face shields for your organization, but please note the following:
* We are currently not distributing to individuals for home or personal use.
* These shields DO NOT replace the use of an appropriate mask (N95 or otherwise).
* These shields are NOT approved for use by any central governing authority.
* We are NOT operating on a first-come, first-served basis. We are using a triage process for requests.
* ALL of the materials used in our production are donated from individuals, businesses or InkSmith.
* These shields have no warranty, no guarantee for fitness of use, and should be cleaned by you before use. A waiver will be required to be signed upon delivery or pickup.

Please answer all questions as completely and thoroughly as possible. We will only contact you when we have shields for you.

If you require Health Canada approved shields, or quantities in excess of 50 units, please contact InkSmith to purchase the approved Canadian Shield instead: https://www.canadianshieldppe.ca

If you want to JOIN the production effort with your 3D printer please join our online community on Slack: https://join.slack.com/t/communityppeworkspace/shared_invite/zt-d0q2sxw6-t56SCajVoEhk4EEtwbBHzw Please do NOT join the community to beg for shields. We are working as fast as we can.
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What is your email? *
What is your name? *
What is your mobile cell phone number? *
What is the name of your organization, practice or facility? *
What is your role in the organization? *
Do you understand that these face shields are NOT approved for use by Health Canada, Ontario Health or any other governing body? *
Do you have approval to use uncertified PPE in your organization or facility? *
What type of facility or practice will these be used in? *
Please describe how these face shields will be used. *
How many face shields do you need? We suggest at MOST two per staff member. *
Will you do your best to wash and clean the shields for re-use until supply catches up with demand? Our research suggests 10 minutes submerged soaking in warm water and soap, or 10 minutes in a 1:50 bleach:water solution. *
Some of the elastic headband material we have contains 30% latex. We have extremely limited supply of latex-free elastic back straps. What do you require?
Do you require delivery of the shields by our volunteers or can you arrange to pick them up in Kitchener/Waterloo? *
If you require delivery or shipping, to what address?
I agree that the Community Shield is provided as-is and is not guaranteed to be sterile (or any level of clean). I understand that the default elastic back strap contains 30% latex. I agree that I will inform all users of this equipment of these facts and request that they wash and reuse the shield for as long as is practical. I agree, and can legally bind my organization, to not hold the volunteers, organizations or suppliers of the Community Shield liable for any failure of these shields to provide adequate protection in any circumstance. *
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