Region 6 Healthcare Coalition PPE Survey

1. Agency Contact Information *This question is required.

First Name

Last Name

Title

Agency Name

Email Address

Phone Number

2. Please record your current number of N-95 face masks available. *This question is required.

3. Please record your normal PAR level for N-95 face masks. *This question is required.

4. Please record you current number of masks with face shields. *This question is required.

5. Please record your normal PAR level of masks with face shields.

6. Please record your current number of surgical masks available. *This question is required.

7. Please record your normal PAR level of surgical masks. *This question is required.

8. Please record the department's current number of infection control kits available. *This question is required.

9. Please record the department's normal PAR level of infection control kits. *This question is required.

10. Please record the department's number of current goggles/eye protection available. *This question is required.

11. Please record the department's normal PAR level of goggles/eye protection. *This question is required.

12. Please record the department's current number of PAPR/CAPR's available. *This question is required.

13. Please record the department's normal PAR level of PAPR/CAPR's. *This question is required.

14. Please mark all supplies that your department is able to currently resupply through normal purchasing processes. *This question is required.