Personal Protective Equipment (PPE) Request Form

Please complete all fields below. If a category or question is not applicable, please write N/A.

Requester Information


General Office Needs

Washable, Cloth, SJU-logo Face Covering

(Distribution: 1 mask per employee; please provide a separate list of employees’ names)

One file only.
256 MB limit.
Allowed types: pdf, doc, docx, xls, xlsx.

Sanitizing Wipes (~75/cannister)

Particular Departmental/Clinical Needs

Non-Latex Gloves (box) (~200/box)

Please indicate Size (M, L, XL) and amount of boxes needed per size in the quantity response.

N95 Respirator (NIOSH-Approved)

FDA-Approved KN95 Respirator

Level 3 Surgical Mask

3-ply Disposable Mask

Face Shields

Medical/Surgical Gown

Hand Sanitizer (~8 oz./container)

Chemical Splash Goggles

Non-Contact Thermometer

PPE Status

What is the status of PPE in your Department/Unit?
Do you expect a change in your rate of use?
How long do you estimate the requested PPE will last?