Portal PPE Requests

Personal Protective Equipment (PPE) Request Effective 5/20/2020
This form will shut down on May 17th, 2021. Click here for more details about PPE distribution ending.

If desired items are not identified on this fillable form, a separate request will need to be submitted through your city or county’s Office of Emergency Management who will submit it to the State of Texas Assistance Request (STAR) system. We will contact your organization within 96 hours if we are able to fill/partial fill your request. Requestor may resubmit after 96 hours if PPE quantity or item is unable to be obtained via their normal procurement methods. Re-submissions prior to the 96 hour time limit will automatically be rejected, and will reset the 96 hour time minimum.

NOTE: All PPE pickups will occur at the NCTTRAC warehouse in Arlington.
Distribution Considerations

Hospitals or providers in contact with or treating confirmed COVID patients with potential for high loss of life.

Health care facilities, including long-term care with an emerging or active outbreak

Facilities and EMS personnel that may encounter a suspected case and interface with a vulnerable population.

Health care facilities, providers and first responders that have general patient encounters and needs.
Entity Name*
Entity Type*
Other: Enter Here if your Entity Type is NOT Listed. ISDs and Election Sites should not request PPE through this form. Those entities should contact their city/county office of emergency management to submit a STAR request to TDEM
Is this a request for Multiple Facilities?
List Agencies/Organizations by Location (City)
DSHS License Number
Texas State License Number
Entity Street Address*
City*
County*
Texas Zip Code*
Requestor First Name*
Requestor Last Name*
Requestor Phone Number*
Requestor Email*
example@example.com
Requestor Title
Authorized Pick-Up Person (Must match name on Driver’s License)
Pick-Up Person First Name*
Pick-Up Person Last Name*
Phone Number*
Please enter a valid phone number.
Title
Email
PPE Resource Request Criteria

Determine your Burn Rate after implementing PPE conservation strategies by using the below calculation formula:

# of Staff in Patient Contact x PPE Ensembles Used Per Person Per Day = Total

Then enter the appropriat amounts into the fields provided.

The calculated total will show in the Total window.
# of Staff in Patient Contact*
PPE Ensembles Per Person Per Day*
PPE Burn Rate Total
Facilities with Inpatients/Residents:
Do you currently have COVID-19 positive patients/encounters?*
Enter unit amounts, do not use boxes or cases (e.g. 2000 Gloves)

Select Items and Sizes*

	Small	Medium	Large	XL	XXL	XXXL	# Days Supply Available
Coveralls
Gloves (Medical)
Gloves (Non-Medical)
Gowns (Medical)
Gowns (Isolation)

Items below are ONE SIZE FITS ALL. Items with asterisks are ancillary to the normal PPE shipments. These items are infrequently available.
Disinfecting Wipes*
Dry Wipes*
Face Shields
Hair Coverings*
Hand Sanitizer*
Mask (KN95)
Masks (N95)
Masks (Surgical/Procedure)
Safety Glasses*
Safety Goggles*
Booties*
PROVIDER RESPONSIBILITIES BEFORE SUBMITTING FOR PPE

Demonstrated implementation of conservation/life extension strategies as identified by the CDC

Exhausted all means of commercial procurement prior to submitting this request.

Exhausted community assistance options, including coordination with local partners and facilities for reallocation within regions.

Provided PPE Daily Burn Rate

By submitting this form, I attest, to the best of my knowledge, that my agency/facility has met the Provider Responsibilities above before submitting for PPE from the State-sourced cache and that the information herein is true, correct and complete.
Name*
Title (Senior Executive Equivalent)*
Date*

MonthDayYear
Date
Should be Empty:

Personal Protective Equipment (PPE) Request Effective 5/20/2020

Authorized Pick-Up Person (Must match name on Driver’s License)

Facilities with Inpatients/Residents:

Enter unit amounts, do not use boxes or cases (e.g. 2000 Gloves)