Community Organization Personal Protective Equipment (PPE) Request Form

Per Erie County Legislature Resolution, Erie County has made a limited amount of personal protective equipment (PPE) available to community groups, youth programs, block clubs, community centers and faith institutions/places of worship. The intent of this program is to ensure organizations providing services to seniors, people with disabilities, culturally specific communities, communities of color, people with underlying health conditions, people living in congregate settings, people experiencing homelessness and groups impacted by inequities have an opportunity to get PPE supplies from Erie County to reduce the spread of COVID-19.

Groups are encouraged to complete and submit this form. Applications will be reviewed and fulfilled based on supply availability and anticipated positive impact by your organization’s distribution

Items that can be requested include:

Non-surgical masks (50/box)
Disinfectant wipes (80-100/canister)
At-home COVID-19 antigen test kits (2/box; 90 boxes/case)

Thank you for helping to keep our community safe and healthy.

Organization Name

Phone Number

Email

Name of person picking up the items

Is your organizations a 501C3?

Describe the population your organizer serves

Approximate number of people your organization serves

Describe how this PPE will be utilized and distributed

Please describe why your organization need this equipment and include efforts made to purchase equipment elsewhere

Select the item(s) and fill in the quantity of each that you are requesting

Non-surgical masks (50/box)

Quantity Requested

Disinfectant wipes (80-100/canister)

Quantity Requested

At-home COVID-19 antigen test kits (2/box; 90 boxes/case)

Quantity Requested