Personal Protective Equipment (PPE) Needs Survey

The Illinois Department of Human Services (IDHS) has procured various types of personal protective equipment (PPE) for IDHS providers throughout the State to supplement the PPE provider organizations are able to procure on their own. This distribution is only available for health and human service providers who receive funding from the Illinois Department of Human Services. This survey is designed to provide IDHS an overview of the services provided by your organization along with an estimate of the needed PPE.

Please note - supplies are limited; filling out this survey does not guarantee you will receive all of the supplies indicated in your submission. IDHS will attempt to fulfill all requests for PPE and reserves the right to allocate based on Agency discretion and the type of setting in which your organization operates. Once you submit this survey, your organization will be scheduled for regular monthly delivery of PPE until all PPE is exhausted in this supply.

If your organization has multiple site locations throughout the State, please identify only one location as the primary recipient for the PPE distribution.

Please complete the following survey before end of day January 20, 2021 indicating the quantity of PPE your organization will need for staff and clients thirty (30) days, if following the CDC's recommended guidelines for reuse.

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