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.

Address for PPE delivery (in the event direct delivery is available)

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Please specify the item count (exact item amount, not cases) needed for each of the below (30-day quantity):

PPE Count for Staff Count for Clients
Isolation Gowns - Level 2 (One Size Fits All)
Available in cases of 50
Isolation Gowns - Level 2 (Large)
Available in cases of 50
Isolation Gowns - Level 2 (XL)
Available in cases of 50
Isolation Gowns - Level 2 (2XL)
Available in cases of 50
Isolation Gowns - Level 2 (3XL)
Available in cases of 50
Isolation Gowns - Level 2 (4XL)
Available in cases of 50
Isolation Gowns - Level 2 (5XL)
Available in cases of 50
Nitrile Gloves Box (Small)
Available in cases of 100
Nitrile Gloves Box (Medium)
Available in cases of 50
Nitrile Gloves Box (Large)
Available in cases of 50
Nitrile Gloves Box (XL)
Available in cases of 50
Reusable Face Shields
Available in cases of 50
Pairs of Shoe Coverings
Available in cases of 100
Surgical Masks
Available in cases of 50
Waterproof Elastic Disposable Hair Bonnets
Available in cases of 200

Please specify the item count (exact item amount, not cases) needed for each of the below (30-day quantity):

Cleaning/Sanitizing Items Count for Staff Count for Clients
Disinfecting Wipes - 50 ct packs
Disinfecting Wipes - 60 ct packs
Disinfecting Wipes - 80 ct canisters
Disinfecting Wipes - 160 ct canisters
Hand Sanitizer - 16 oz bottle with pump
Available in cases of 60
Hand Sanitizer - 4 oz bottle
Available in cases of 60

Please specify the item count (exact item amount, not cases) needed for each of the below (one-time shipment):

Reusable Items Count

Please confirm you are a provider with an IDHS service relationship by indicating which division(s) your organization works with:

Do you provide services to people who are at-risk and/or high-risk of exposure to COVID-19? Please indicate which by using the options below:
* Please refer to the CDC's guidelines for more information on at-risk populations (https://www.cdc.gov/coronavirus/2019-nCoV/index.html)
In completing this form, to the best of my ability I have accurately represented our organization's need. Additionally, I specifically acknowledge the requirements recited at the top of this survey regarding eligibility to receive any amount of PPE. By completing and submitting this form, I acknowledge and agree that no IDHS-allocated PPE shall be used for anything else other than supporting our organization's services through use by staff and customers.