Personal Protective Equipment (PPE) Needs Survey

The deadline to request PPE through this program was January 20, 2021. For more information, please see IDHS Community PPE Program Frequently Asked Questions or contact DHS.PPE@illinois.gov with any questions.

Organization:

Address:

City, State, ZIP:

Contact Name:

Email:

Phone:

Please specify the item count needed for each of the below:

PPE	Count
N-95 Masks (each)
Surgical Masks (each)
Gowns (each)
Face Shields (each)
Goggles (each)
Medical Gloves - size S (box)
Medical Gloves - size M (box)
Medical Gloves - size L (box)
Medical Gloves - size XL (box)

Preventative/Sanitizing Items	Count
Touch-free Thermometer
Hair Covering (each)
Shoe Covering (each)
Hand Sanitizer
Disinfectant Wipes
Ziploc Bags Quart (box) *
Paper Bags (bundle) 12# *
Paper Bags (bundle) 25# *

* if reusing PPE per guidelines

Are there other items needed? If so, please write below, with quantities:

Please note the categories of employees that these items are needed for:

Please give a justification and explanation as to why these items are needed:
(e.g., in home care worker who enters 5 homes per day and must be in close
contact with the client in order to successfully perform job)

Please indicate which, if any, of the following agencies you have contracted with:

• Illinois Department of Human Services
• Illinois Department of Chidlren and Family Services
• Illinois Department of Healthcare and Family Services
• Illinois Department on Aging
• Illinois Department of Public Health
• Illinois Department of Veterans Affairs