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

Address:

City, State, ZIP:

County: Adams Alexander Bond Boone Brown Bureau Calhoun Carroll Cass Champaign Christian Clark Clay Clinton Coles Cook Crawford Cumberland DeKalb DeWitt Douglas DuPage Edgar Edwards Effingham Fayette Ford Franklin Fulton Gallatin Greene Grundy Hamilton Hancock Hardin Henderson Henry Iroquois Jackson Jasper Jefferson Jersey Jo Daviess Johnson Kane Kankakee Kendall Knox Lake LaSalle Lawrence Lee Livingston Logan Macon Macoupin Madison Marion Marshall Mason Massac McDonough McHenry McLean Menard Mercer Monroe Montgomery Morgan Moultrie Ogle Peoria Perry Piatt Pike Pope Pulaski Putnam Randolph Richland Rock Island Saline Sangamon Schuyler Scott Shelby St. Clair Stark Stephenson Tazewell Union Vermilion Wabash Warren Washington Wayne White Whiteside Will Williamson Winnebago Woodford Other

What is the weekly average number of Full-Time employees working in the office:

What is the weekly average number of Part-Time employees working in the office:

What is the weekly average number of clients you serve in an in-person setting:    

Primary Contact Name:

Primary Contact Email Address:

Primary Contact Cell Phone Number:

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
Touch-free Thermometer

Based on your responses to the survey above, is your organization able to securely store a 30-day supply of PPE? Yes No

Does your organization have a loading dock? Yes No

Can your organization accept shipments on weekends and holidays? Yes No

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

• Division of Developmental Disabilities
• Division of Family and Community Services
• Division of Mental Health
• Division of Rehabilitation Services
• Division of Substance Use Prevention and Recovery

Please choose the program that best describes the function of your organization: Best Practices in Inter-Conception Health Better Birth Outcomes Childcare Assistance Program CLF Commodity Supplement Food Program Community Day Services Community Integrated Living Arrangements (CILA) Domestic Violence Prevention and Intervention Early Childhood Development Early Intervention Emergency & Transitional Housing Emergency Food Program Emergency Solutions (ESG) Employment and Training Family Case Management Family Nutrition Farmers Market Health Work Illinois High Risk Infant Follow-Up Home Services Program Homeless Prevention Homeless Youth ICF/DD Illinois Welcoming Centers Immigrant Family Resource Program ISC Job Placement Mental Health Outpatient Program Mental Health Residential Program New Americans Initiative Overdose Prevention Services Partner Abuse Prevention & Intervention Perinatal Depression Positive Youth Development Recovery Support Services Refugee Resettlement Sexual Assault Prevention SNAP Nutrition Education SNAP Outreach Substance Use Counseling Substance Use Disorder Treatment Supportive Housing SUPR Outpatient Services SUPR Residential Services Vocational Rehabilitation Program WIC Youth Intervention Other

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:

• Immunocompromised Individuals *
• Individuals living in congregate care settings
• Individuals living in congregate settings (non-care)
• Individuals with heart or lung conditions *
• Individuals with pre-existing chronic conditions *
• Older Adults
• Other

* 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.

• I acknowledge and agree