Breathe Better Berlin Request Form

1
What's your name?* This field is required. You can use your full name or an alias - up to you!
2
What are your pronouns?
3
What do you need?* This field is required.
Free FFP2 masks
Pluslife SARS-CoV-2 tests
Aranet4 Home CO2 monitor
4
Would you rather be contacted via Email or Signal?* This field is required.
Email
Signal
5
What's your Email?* This field is required.
example@example.com
6
What's your Signal username?* This field is required.
7
What's your phone number? In the past, we sometimes couldn't find people with just their user name. We ask for an additional phone number to make sure we can reach you.
Please enter a valid phone number.
8
What's the name of your organization? If applicable
9
How urgent is your request?
ASAP (trying for within 48 hours)
2 weeks (standard turnaround)
No rush (low priority)
10
What types of masks would you like to receive?* This field is required.
Tri-fold 3M Aura
Bi-fold FFP2
11
How many Tri-fold 3M Aura?For personal use, please limit the amount to 10 masks. If you need more because you're organizing a community event, please specify in the last form field.
12
How many Bi-fold FFP2?For personal use, please limit the amount to 50 masks. If you need more because you're organizing a community event, please specify in the last form field
13
How many Pluslife SARS-CoV-2 tests?Since we have limited supply and want to support as many folks as possible, we are limiting requests to 3 tests per person. We also want to prioritize distributing these tests to folks who most urgently need Pluslife tests to protect themselves, including people who are living with ME, Long Covid, chronic illness and disability & their caregivers. (That said, you do not need to provide any sort of proof of your condition to request these tests!)
14
What do you need the Aranet4 Home CO2 monitor for?This helps us prioritize requests in case we receive multiple at once.
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15
Until when do you anticipate needing it?An estimate is good enough. Generally, we lend out the Aranet for up to one week.
Date
Year
Month
Day
16
Do you have a liability insurance?This is not a requirement, but good for us to know.
YESNO
17
How would you like to organize pick up?You can also choose both options
Meet volunteer somewhere
Delivery
18
What's your address? For delivery
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
What would be a good spot for you to meet up?Like a park nearby, a spot that is easy & accessible for you to reach.
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20
When would drop off/ pickup work best for you?
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Evening
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21
Is someone in your household currently sick with a contagious illness?* This field is required.If yes, we'll try to prioritize your request. Also, we'll try to organize delivery without meeting you directly (to protect ourselves)
YESNO
22
Is there anything else you'd like us to know?
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