Covid-19 Supplies Request

Supply Shortage Urgent Request Form

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

Facility / Agency Name:

Address:

City:

State (abbr):

Zip:

Discipline:

Contact

Requestor Name:

Phone:

Email:

Secondary Contact

Secondary Requestor Name:

Secondary Phone:

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.

If you have an order pending, what is the estimated delivery date?

Are you a member of a health system?

Yes

Health System Name:

Have you requested supplies through your health system?

Yes

N/A

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

Yes

Date supplies are needed by:

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
1
2
3
4
5

Are there any alternative makes and models that are acceptable if the ones specified above are unavailable?

Yes

Please Specify: