Status In Process by RHPC Denied Filled at local/region level Request Validated by RHPC & sent to SHCC Sourced out to diff agency SHCC Staff sent to SEOC (PPE only) Request being handled by MDH MDH request entered in WebEOC Request Completed by MDH Request Denied by MDH
Please add in any notes related to this request (optional):
First Name* must provide value
Last Name* must provide value
Title
Phone Number (must be 24-7)* must provide value
Email* must provide value
Health Care Coalition/Tribal/State Owned Facility* must provide value
Central Health Care System Preparedness Coalition Metro Health and Medical Preparedness Coalition Northeast Heatlh Care Preparedness Coalition Northwest Health Services Coalition South Central Health Care Coalition Southeast Minneosta Disaster Health Coalition Southwest Healthcare Preparedness Coalition West Central Health Care System Preparedness Coalition Tribal Health Care State Owned Facility
Discipline* must provide value
Hospital Long Term Care Ambulance Service Other Assisted Living Home Health Agency Group Home
Other, please describe
Health Care Facility/Agency* must provide value
Shipping Address* must provide value
Shipping City/Town* must provide value
Shipping Zip* must provide value
Available for Weekend Delivery* must provide value
Yes
No
Affiliated Health System (enter N/A if independent)* must provide value
Size of Institution* must provide value
400+ beds 200-399 beds 50-199 beds 1-49 beds
Number of employees (total)* must provide value
Number of direct patient care staff (e.g. RNs, CNAs etc.)* must provide value
Are you currently treating laboratory confirmed COVID-19 patients?* must provide value
10-19 inpatients 5-9 inpatients 1-4 inpatients 0 inpatients 20-29 inpatients 30-39 inpatients 40+ inpatients
Trauma Designation Level 1 Level 2 Level 3 Level 4/CAH Not Applicable
Face masks or surgical masks
* must provide value
Yes
No
5-7 Day Supply Quantity Needed (# of individual masks)
How many days of supply do you have left?
0-3 days 4-7 days 8+ days
N95 Respirator*Please Note per CDC guidance, N95 Respirators are reserved for aerosol generating procedures (AGPs) ONLY
* must provide value
Yes
No
Aerosol Generating Procedures performed on COVID-19 positive patients
Select all that apply
open suctioning of airways
sputum induction
CPR
endotracheal intubation and extubation
bronchoscopy
manual ventilation
non-invasive ventilation
CPAP
5-7 Day Supply Quantity Needed (# of individual masks)
How many days of supply do you have left?
0-3 days 4-7 days 8+ days
Isolation/Disposable Gown* must provide value
Yes
No
5-7 Day Supply Quantity Needed (# of individual gowns)
Do you have laundry service?
Yes
No
How many days of supply do you have left?
0-3 days 4-7 days 8+ days
Gloves* must provide value
Yes
No
5-7 Day Supply Quantity Needed (# of cases, 1000 gloves/case)
Will accept LATEX gloves (will only send if non-latex is not available)
Yes
No
How many days of supply do you have left?
0-3 days 4-7 days 8+ days
Face shields/eye protection* must provide value
Yes
No
5-7 Day Supply Quantity Needed (# of individual shields)
How many days of supply do you have left?
0-3 days 4-7 days 8+ days
Boot Covers Yes
No
5-7 Day Supply Quantity Needed (# of individual boot covers)
How many days supply do you have left?
0-3 days 4-7 days 8+ days
PAPR Hoods/Covers Yes
No
Quantity Needed (individual items)
Size
How many days of supply do you have left? 0-3 days 4-7 days 8+ days
Ventilators (Hospitals Only) Yes
No
Quantity Needed (individual items)
How many days of supply do you have left? 0-3 days 4-7 days 8+ days
BiPaP Machines (Hospitals Only)* must provide value
Yes
No
Quantity Needed (individual items) 1 2
Infrared Thermometer* must provide value
Yes
No
Quantity Needed (individual items)* must provide value
Do you have a written respiratory protection program?* must provide value
Yes No
Please upload your respiratory protection program policy or procedure.
Have your staff been medically evaluated to wear N95 respirators?* must provide value
Yes No
Are your staff fit tested for N95 respirators?* must provide value
Yes No
Have you attempted to obtain item(s) in question from another vendor/supplier?* must provide value
Yes
No
If so, who?
Please upload documentation that demonstrates you have tried to obtain requested PPE from at least two vendors and were unable to do so. Documentation must include all items requested.
Space to upload additional documentation, as needed.
Have you contacted any local or system partners to resolve your supply request?* must provide value
Yes
No
If so, who?
Have you formally requested these resources from your Health Care Coalition (e.g. HCC Regional Request Process)?* must provide value
Yes
No
Have you reached out to your local Emergency Manager for assistance in getting PPE? Yes
No
How many days of supply do you have left?
What conservation strategies are you using for each reported shortage?* must provide value
Please upload your file with updated calculations here:
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