PPE Request

NOTE: Some items in our inventory have exceeded their expiration dates but are still usable depending on the intended purpose.

Please fill out this PPE request form to the best of your abilities. Your request will be sent to the MCDPH Logistics Team for review and prioritization.

If you are looking for volunteers for a Vaccine Event, please use the following link and complete that form: Vaccine Event Resource Request.

If you need support volunteers/staff for a K-12 school, please use the following link and complete that form: K-12 Support Request.

Contact Information

If you are a Private Practice or Private Doctor’s Office please go to the Maricopa County Medical Society for requesting PPE. Click here for their Request Form!

Please provide the contact information for the person completing this form. For questions contact

First Name

Last Name

Phone Number

Email Address

Director of Nursing/Supply Chain Manager/Principal or Superintendent

Please provide the contact information for the person that can discuss or manages PPE inventory needs for your organization.

Same as above

First Name

Last Name

Phone Number

Email Address

Facility Information

Facility Name

Organization Type

Delivery Location

Street Address

City

State

Zip Code

Patient and Staffing Overview (for Healthcare facilities only)

Are you actively testing patients for COVID-19?

Yes

No

Do you currently have COVID-19 positive patients?

Yes

No

Number of COVID-19 Positive Patients

How many patients do you currently have in your facility?

How many staff do you have working in your facility in a 24 hour period?

Do you have specific staff assigned to work with COVID19 positive patients?

Yes

No

If yes, how many?

Daily Burn Rate

Complete for PPE requests only. Otherwise click the next arrow below.
Please indicate how much of each PPE item your entire facility uses and discards within 24 hours.

Do you know your PPE Daily Burn Rate?

Yes

No

Please indicate each PPE item by single item, not boxes or cases.

N95 Respirator

Face Mask or Surgical Mask

Face Shield

Glove

Please group all sizes and types of gloves together. Count gloves as individual gloves and not as pairs of gloves.

Isolation Gown

Inventory

How many of each PPE item do you currently have on hand? Without this information we cannot process your request for prioritization. Please indicate each PPE item by single item, not boxes or cases.

Do you know your PPE Inventory?

Yes No

Please indicate each PPE item by single item, not boxes or cases.

N95 Respirator

Face Mask or Surgical Mask

Face Shield

Glove

Please group all sizes and types of gloves together. Count gloves as individual gloves and not as pairs of gloves.

Isolation Gown

PPE Request

Please indicate each PPE item by single item, not boxes or cases.

N95 Respirator

Only for medical/healthcare use in Covid-19 activities

Face Mask or Surgical Mask

Face Shield

Gloves - X Large

Isolation Gown - One Size

Vaccination Supplies Information

Complete for Vaccine Supply requests only. Otherwise click the next arrow below.
Please indicate each vaccination item by box, not single item.

Medical Supplies

Bandages (2400 per box)

Goggles

Safety Glasses

Hand Sanitizer 1.7 oz

Hand Sanitizer 8 oz

Hand Sanitizer 16 oz

Hand Sanitizer 33 oz

Sanitizing Wipes (supplies limited)

Sharps Container - 2 Gallon

Sharps Container - 3 Gallon

Sharps Container - 8 Gallon

Sharps Container - 9 Gallon

Documentation

I got vaccinated Stickers (13750 per case)

I got vaccinated Stickers - Spanish (275 per roll)

Testing Supplies Information

Please indicate each testing supply item below by single item, not boxes or cases.

Only submit one request, if there is availability we will reach out to you (multiple requests will delay deployment of critical care PPE)

OTC At - Home self tests (12 per package)

- For use on symptomatic individuals presenting symptoms consistent with COVID-19.
- CLIA Waiver not required for these OTC Covid test kits
- Not for use in screening asymptomatic individuals for COVID-19
- Positive Test results can be reported to Maricopa County Public Health
- OTC Covid test kit must be stored and kept between 35.6 – 86.00 degrees Fahrenheit
- For more information, please see the video at the following link: HOW TO: A Guide for the BinaxNOW™ COVID-19 Self Test - YouTube

IR Thermometers

Statement of Responsibility

My organization accepts responsibility for the supplies that may be issued and will distribute to them as needed. This is a one-time delivery with no expectation to return remaining supplies or reimburse Maricopa County Department of Public Health. My organization is not being charged for these supplies contained in this order form only. As a result, 𝐈 𝐜𝐚𝐧𝐧𝐨𝐭 𝐜𝐡𝐚𝐫𝐠𝐞 𝐜𝐥𝐢𝐞𝐧𝐭𝐬/𝐩𝐚𝐭𝐢𝐞𝐧𝐭𝐬 for the use of these supplies. By clicking "𝐘𝐞𝐬" you agree to the above terms.

Yes

Public Health Supplies Request Form

Contact Information

Director of Nursing/Supply Chain Manager/Principal or Superintendent

Facility Information

Patient and Staffing Overview (for Healthcare facilities only)

Daily Burn Rate

Inventory

PPE Request

Vaccination Supplies Information

Medical Supplies

Documentation

Testing Supplies Information

Statement of Responsibility