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We need your help because we are hearing from state partners that our homes have plenty of PPE.

If that is not the case, we need to tell your story.  Please complete this by June 5, 2020.

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* 1. Organization

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* 2. Contact Name

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* 3. Email address

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* 4. County

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* 5. Number of Residents (average daily census)

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* 6. Number of Staff

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* 7. Are you using home made PPE in your LTC community?

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* 8. Are you re-using PPE in your LTC Community?

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* 9. How many KN95 Masks do you currently have on hand?

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* 10. How many more KN95 Masks would you need if you were to have an outbreak?

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* 11. How many N95 Masks do you currently have on hand?

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* 12. How many more N95 Masks would you need if you were to have an outbreak?

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* 13. How many Surgical Masks do you currently have on hand?

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* 14. How many more Surgical Masks would you need if you had an outbreak?

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* 15. How many Gowns do you currently have on hand?

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* 16. How many more Gowns would you need if you had an outbreak?

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* 17. How many Face Shields do you currently have on hand?

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* 18. How many more Face Shields would you need if you have an outbreak?

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* 19. How many Goggles do you currently have on hand?

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* 20. How many more Goggles would you need if you had an outbreak?

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* 21. How many Medical Gloves (boxes) do you currently have on hand?

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* 22. How many more Medical Gloves (boxes) would you need if you had an outbreak?

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* 23. How much Hand Sanitizer do you currently have on hand?

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* 24. How much Hand Sanitizer would you need if you had an outbreak?

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* 25. How many Thermometers do you currently have on hand?

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* 26. How many more Thermometers would you need if you had an outbreak?

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* 27. Have you reached out to your local Emergency Manager to request PPE?

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* 28. If yes, did they supply PPE?  How much and what kind?

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* 29. Have you received your PPE Shipment from FEMA?

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* 30. If you have received your PPE supply from FEMA, How would you rate the quality of the supply? (skip this if you have not received your supply)

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* 31. Who is your best source for PPE at this current time?

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