In Process by RHPC Denied Filled at local/region level Request Validated by RHPC & sent to warehouse 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
Full approval Partial approval
Please add in any notes related to this request (optional):
First Name
* must provide value
Last Name
* must provide value
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
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.)
Does not include administration, dietary or environmental services
* must provide value
Number of residents in 14-day quarantine (e.g. New or re-admissions, residents exposed to positive person)
* 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
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
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
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
Yes
No
Quantity Needed (individual items)
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)
Note: This information is used to create an allocation list for further distributions. There is no guarantee you will receive the requested quantity.
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
Pulse Oximeter
* must provide value
Yes
No
Quantity Needed
* must provide value
1 2
Our facility has or will implement the standards identified by OSHA and CDC related to N95 respirators.
* must provide value
Yes
No
Do you have a written respiratory protection program?
Yes No
Please upload your respiratory protection program policy or procedure.
*Must be completed if you've indicated yes. Failure to do so will result in a delay of your PPE request being processed.
Have your staff been medically evaluated to wear N95 respirators?
Yes No
Are your staff fit tested for N95 respirators?
Yes No
Have you attempted to obtain item(s) in question from another vendor/supplier?
This is required to receive PPE from the state warehouse.
Contact your health care coalition for assistance with identifying potential PPE vendors.
* must provide value
Yes
No
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.
Documentation should be dated within 1 week of the PPE request.
Acceptable documentation must come from the vendor or supplier and could be an email from a vendor or an invoice listing back ordered product.
* must provide value
Space to upload additional vendor documentation, as needed.
STOP Have you uploaded the required documentation? Without documentation, your request will be automatically denied.
Have you contacted any local or system partners to resolve your supply request?
* must provide value
Yes
No
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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