PPE & Rapid COVID Test Request Form

SUPPLY REQUEST
for
Personal Protective Equipment &
Rapid COVID-19 Test Kits

This portal can be used to order PPE and rapid antigen test kits from the Larimer County Department of Health and Environment (LCDHE). The Department will review each order and can deny, alter, or delay any order without notification. Approved orders are fulfilled during the normal work week (Monday - Friday).

Supply requests are considered on the basis of urgency (nature of an emergent request), the availability of products, and whether or not the requesting agency has exhausted available options to obtain supplies. Please be advised there is no guarantee on fulfillment of orders or the timeline resources will be allocated.

The requesting agency must pick-up supplies at a location to be determined once the application has been approved. Supplies cannot be shipped.

Requesting Agency Must Complete This Form

(Form posted to: https://www.larimer.gov/health/emergency-preparedness-and-response)
ABOUT YOU

Point-of-Contact
Full Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
E-mail *
example@example.com
Requesting Agency
Organization Name *
Organization Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Staff: *
Number of Clients/Residents/Attendees: *
Organization Type *
If "Other" selected, please describe: *
SUPPLY REQUEST

What type of supplies are you requesting? Please select the items you need and indicate the type/size and quantity where indicated. You can select more than one item.
PPE *

N-95 Particulate Masks N-95 Medical Grade Masks Surgical Masks Disposable Gowns Disposable Nitrile Gloves Face Shields
Quantity of N-95 Particulate Masks *
Quantity of N-95 Medical Grade Masks *
Surgical Mask Type: *

ASTM-2 ASTM-3
Quantity of ASTM-2 Masks: *
Quantity of ASTM-3 Masks: *
Disposable Gown Sizes *

Small Medium Large XL 2XL
Quantity of Disposable Gowns (Small): *
Quantity of Disposable Gowns (Medium): *
Quantity of Disposable Gowns (Large): *
Quantity of Disposable Gowns (XL) *
Quantity of Disposable Gowns (2XL) *
Disposable Nitrile Gloves Sizes *

Small Medium Large XL 2XL
Quantity of Disposable Nitrile Gloves (Small) *
Quantity of Disposable Nitrile Gloves (Medium) *
Quantity of Disposable Nitrile Gloves (Large) *
Quantity of Disposable Nitrile Gloves (XL) *
Quantity of Disposable Nitrile Gloves (2XL) *
Quantity of Face Shields: *
PPE
N-95 Particulate Masks quantity
N-95 Medical-Grade Masks   quantity
Surgical Masks
ASTM-2:     quantity
ASTM-3    quantity
Disposable Gowns

Small:     quantity

Medium:      quantity

Large:      quantity

XL      quantity

2XL      quantity

Disposable Nitrile Gloves

Small:     quantity

Medium:        quantity

Large:   quantity

XL:    quantity

2XL   quantity

Face Shields       quantity

COVID-19 Antigen Test Kits
(Note: Each kit contains 2 tests)
Self-administer rapid antigen test kits     quantity
Point-of-Care rapid antigen test kits          quantity
COVID-19 Antigen Test Kits (Note: Each kit contains 2 tests): *

Self-administer rapid antigen test kits Point-of-Care rapid antigen test kits
Quantity of self-administer rapid antigen test kits: *
Quantity of Point-of-Care rapid antigen test kits: *
SUPPLY QUESTIONS
Is this an urgent request for supplies? *

Yes No
If yes, please describe the nature of the emergent situation. *
Do you have an existing supplier/vendor for the items you are requesting above? *

Yes No
If yes, who is your primary supplier/vendor for these supplies? Select all that apply. *

Amazon BoundTree Columbine Medical Grainger Henry Schein Lincare McKesson Vitality Medical Other
When did you last place an order for these items (with LCDHE or elsewhere)? *
When did you last place an order for these items (with LCDHE or elsewhere)? *

Month Day Year
Date
Do you have any pending orders awaiting to be received? *

Yes No
If yes, when is the expected delivery date? *

Month Day Year
Date
What facilities or organizations within our region have you contacted to request supplies? *
Point-of-Contact for this facility or organization:
Name:    First Name*   Last Name*
Phone:   Area Code*   Phone Number*
Email:   Email*
ACKNOWLEDGEMENT: In the event you do not use all of the PPE, you will coordinate with LCDHE to return unused materials. *

Clear
Additional Comments:
Should be Empty:

ABOUT YOU

SUPPLY REQUEST

SUPPLY QUESTIONS