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PPE Request Form
The Maryland Department of Health (MDH) is reaching out to offer a one-time supply of personal protective equipment (PPE) to dairy workers in Maryland who don’t already have the PPE available.
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Contact Information: First and Last Name
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Your answer
Contact Information: Email Address
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Your answer
Contact Information: Phone Number
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Your answer
Farm/Organization Name
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Your answer
Farm/Organization Address (Street Name, City, State, Zip Code)
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Your answer
Farm/Organization County
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Your answer
How many employees does your farm/organization employ?
Your answer
How many of these employees work directly with animals or with associated materials/ in work areas frequented by animals?
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Your answer
Is your farm/organization in need of a one-time supply of PPE? If so, which of the below items are needed?
Fluid-resistant coveralls
NIOSH Approved® Respirator (e.g., N95® filtering facepiece respirator)
Safety goggles or face shields
Gloves
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This form was created inside of State of Maryland.
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