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Dane County Emergency Management
Dane County Emergency Management PPE Request Form
Fill out the form below to request PPE from Dane County.
Instructions
PPE Calculator
Contact Name
Contact Email
Phone Number
Organization
How many healthcare providers are employed
Has a COVID positive patient been identified at your facility?
Yes
No
Delivery Address
Other Needs
Priority #1
Type of PPE
N95 masks
Surgical masks
Gloves
Gowns
Face Shields
Hand Sanitizer
Cleaning products
Crisis Level
Red (<72 hours)
Yellow (<120 hours)
Green (>120 hours)
Quantity
Priority #2
Type of PPE
N95 masks
Surgical masks
Gloves
Gowns
Face Shields
Hand Sanitizer
Cleaning products
Crisis Level
Red (<72 hours)
Yellow (<120 hours)
Green (>120 hours)
Quantity
Priority #3
Type of PPE
N95 masks
Surgical masks
Gloves
Gowns
Face Shields
Hand Sanitizer
Cleaning products
Crisis Level
Red (<72 hours)
Yellow (<120 hours)
Green (>120 hours)
Quantity
Submit Form
