Covid-19 Supplies Request

Supply Shortage Urgent Request Form

This form is for urgent, healthcare supplies only. For the Small Business Supply Request Form, click here

This form should only be used by entities within Suffolk County.
Entities within Nassau County should contact Nassau county OEM.

Please be aware that we use information shared between NYS and Suffolk County in evaluating and allocating PPE requests.

Facility / Agency Name:

Address:

City:

State:

Zip:

Discipline:

Contact

Requestor Name:

Phone / Direct Mobile #:

Email:

Secondary Contact

(Must Be A Different Person)

Secondary Requestor Name:

Secondary Phone / Direct Mobile #:

Secondary Email:

Description of resource needed:

Have you exhausted all purchasing options at your agency or systems disposal?

Yes

Please list all vendors you have contacted.

Are you a member of a health system or part of a larger practice?

Yes

If yes, please provide the name of the health system or practice:

Have you requested supplies through your health system or practice?

Yes

Have you exhausted any potential mutual aid agreements or association agreements?

Yes

Please tell us the types of health care supplies you are requesting and your current usage rate:

#	Product Type	Size (If Appl.)	Quantity / # of Pieces (Not cartons or boxes)	Quantity Used Per Week	Quantity Currently On Hand
1
2
3
4
5

To the best of my knowledge, I am submitting accurate information related to my current inventory of healthcare supplies and current usage rates. I am submitting a request on behalf of an organization, practice or agency that is currently in practice, currently providing essential services to Suffolk County residents, and the address provided in the form is valid.