Community Organization Personal Protective Equipment (PPE) Request Form

Per Erie County Legislature Resolution the Department of Homeland Security and Emergency Services in conjunction with the Health Department has made available to community groups, youth programs, block clubs, community centers and faith institutions/places of worship a limited amount of personal protective equipment (PPE). The intent of this program is to insure organizations providing services to seniors, people with disabilities, culturally-specific communities, communities of color, people with underlying health conditions, people living in congregate settings, homeless and groups impacted by inequities have an opportunity to get PPE gear from Erie County for the expressed intent of reducing the spread of COVID-19.

Groups are encouraged to complete and submit this form. Applications will be reviewed and fulfilled based on availability of supplies and anticipated positive impact by your organizations distribution.

Requested items can include:
1. non-surgical masks
2. no-touch infrared forehead thermometers
3. hand sanitizer
4. disinfectant wipes

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

Organization Name

Address

City/Town

State/Province

ZIP/Postal Code

Contact Name

24-hour phone number

Name of person picking up the items

Is your organizations a 501C3?

Name of Legislator

Describe the population your organizer serves

Approximate number of people your organization serves

Personal Protective Equipment (PPE) and amount of each item requested at this time

Amount of each item needed weekly

Amount of each item needed monthly

How will this PPE be utilized and distributed

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