Covid-19 Demand Data Collection - Public Spend Forum

Covid-19 - Urgent PPE Supplies Request Form

Complete this request form and our team will promptly send you a potential list of suppliers that match your requirement, based on a combination of our machine learning algorithms recommendations and our analyst team research.

Name*
First Last
Requestor Title/Profession
- Doctor
- Researcher
- Healthcare Staff
- Hospital Administrator
- Government Agency
Requester Phone Number
Requester Email*
Requester Profile (LinkedIn, Institution page, etc.)
Are you the procurement contact?
- Yes
- No
Type of Requesting Organization
What products are you trying to procure?*
Product Description Quantity
How soon will your organization run out of critical equipment/supplies?
- Already out of stock
- Less than a week
- 1-2 weeks
- 2-4 weeks
- Over a month
Is your request on behalf of individuals authorized to operate under current state executive orders?
- Yes
- No
Name of Organization*
Organization Website
Organization Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ambulatory Surgery Center
County/ City
Dental
Federally qualified health center
First responder (police, ambulance, fire dept., etc.)
Funeral home
Home health care/ Hospice
Homeless Services
Hospital
Military hospital or clinic
Pharmacy/ Storefront
Residential facility
Rural health services
Social services organization
State government entity
Federal government entity
Local government entity
Urgent care
VA Provider
Free Clinics

Product	Description	Quantity