VHEPC PortaCount Request Form

PortaCount Request Form

In order to utilize the VHEPC PortaCounts, it is a requirement that staff already be trained to use this equipment and have a Respiratory Protection Plan in place.

NOTE: Submission of the request form does NOT guarantee a PortaCount will be sent to your facility on your preferred dates. PortaCount use is subject to the availability of the PortaCount machines.
My staff are already trained to use this equipment.

YesNo
My organization has a Respiratory Protection Plan in place.

YesNo
My organization has submitted a signed VHEPC member agreement.

YesNoUnknown

Additional Information Required

Based on your responses, you are NOT eligible to submit a VHEPC Porta Count Request.

Please complete ALL of the following prior to attempting a VHEPC Porta Count Request for submission:
- Ensure staff are trained to use this equipment.
- Develop a Respiratory Protection Plan.
- Complete and submit the VHEPC Member Survey.
- Complete and submit a VHEPC New Member Agreement Form.
If you have questions or concerns, please contact the VHEPC Readiness and Response Coordinator at VHEPC@AllClearEMG.com

Name*

First NameLast Name
Facility*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Does your facility own a PortaCount machine?*

YesNo
What length of time is your facility requesting the PortaCount machine for?*
What region is your facility located in *
Address to Deliver PortaCount to:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate your three prefered dates to receive a PortaCount machine below.

To check available PortaCount dates, please refer to our PortaCount Availability Calendar linked HERE.
What is your first date preference to receive a PortaCount machine?*

MonthDayYear
Date
What is your second date preference to receive a PortaCount machine?*

MonthDayYear
Date
What is your third date preference to receive a PortaCount Machine?*

MonthDayYear
Date
I acknowledge that by submitting this request, I am not guaranteed the use of a PortaCount machine. I also acknowledge that I have read and agree to the terms and conditions related to borrowing a PortaCount machine. Please acknowledge so by typing your name below.
Type Name Here*
Should be Empty: