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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
Organization Address
Address
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
Contact Name
24-hour phone number
Email
Name of person picking up the items
Is your organizations a 501C3?
- Select -
Yes
No
Name of Legislator
- Select -
District 1 - Hon. Howard Johnson
District 2 - Hon. April N.M. Baskin
District 3 - Hon. Lisa Chimera
District 4 - Hon. Kevin R. Hardwick
District 5 - Hon. Jeanne M. Vinal
District 6 - Hon. Edward A. Rath, III
District 7 - Hon. Timothy Meyers
District 8 - Hon. Frank J. Todaro
District 9 - Hon. John J. Gilmour
District 10 - Hon. Joseph C. Lorigo
District 11 - Hon. John J. Mills
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