Personal Protective Equipment (PPE) Request Form

 

The Marion County Public Health Department (MCPHD) is currently accepting (PPE) request forms only from dental and medical offices that reside in Marion County. All PPE requests must be submitted on a resource request form and emailed to ESF8Desk@marionhealth.org. Please see the instructions below for completing the request form- incorrect submission of the form will result in delays.

 

213RR Instructions
1. Incident Name: Covid-19
2. Date/Time-date and time form submitted
3. Resource Request Number-leave blank
4. Order:
a. Qty: filled by the case not individual items
b. Kind-leave blank
c. Type: leave blank
d. Detailed Item description-describe the item
5. Requested Delivery/Reporting Location: Include all of the following information in this Section
a. Facility Name
b. Delivery address-including door number, if applicable.
c. Name of person to contact for delivery
d. 24/7 cell number of that contact person
6. Suitable Substitutes-Leave blank
7. Requested by Name/Position: Name of person making the request
8. Priority: Select appropriate level
9. Sections 9 through 19: Leave blank

Please click here to download the PPE request form.

Please click here to an example of how the PPE request form should be filled out.

 

Note- The completed form should be emailed to ESF8Desk@MarionHealth.org as an attachment (PDF); do not attach a picture/jpeg/png of the completed form. Handwritten forms may result in a processing delay as handwriting and ink can be difficult to read once the document has been printed.

MCPHD is making every effort to conserve and equitably distribute PPE quickly. As you can image, we are receiving a large amount of requests, so please be patient with us as we work to fulfill as many as we can.