GNYHA
All requests should be submitted to the GNYHA Office of Emergency Management Desk at: COVIDSupplies@. Please note Organization Name and ‘Supply Request’ in email subject.ALL sections of this form MUST be completed for request to be submitted.As a reminder, there will be costs associated with this supply request. Please limit order size to ONE (1) WEEK of anticipated demand for the product.Requestor InformationAgency/Facility Name: Association: Requestor Name: Requestor Title: Requestor Phone #: Requestor Email: Have You Discussed this Requested with Your Organizations Supply Chain Executive?: Resource Requests for Medical Supplies – all columns must be completed for all requested itemsManufacturer NameModel Numbers/ Manufacturer NumberItem DescriptionTotal Units Requested/ Unit of MeasureHow Many Days Does Your Organization Currently Have On Hand?How many days would requested supply support operations/ current burn rateAlternative Manufacturer and Model NumbersAre you willing to Accept a Different Manufacturer Functional Equivalent? (Y/N)PPE Questions Are employees fit tested on N95’s through an established respiratory protection program? If so, what make and model were they fit tested on??No ? Yes, make/model: Has the agency/facility made a purchase of the requested N95’s/ PPE within the last year??No ? YesWhat type of medical service do you provide?: For what purpose are you using the N95’s/ PPE?: Additional Resource Request Information (All Supplies)Have you exhausted all purchasing options at your facility’s disposal?? ?No ? YesHave you exhausted any potential mutual aid agreements or association agreements? ?No ? YesPlease list all vendors you have contacted.If you have an order pending, what is the estimated delivery date? Delivery InformationStreet Information:Borough and Zip Code:Delivery Point Of Contact Name/ Title: Delivery Point Of Contact Phone #/ Email Address: Specific Delivery Instructions: Please email COVIDSupplies@ with any follow up questions. For GNYHA Review ONLYReview Staff Member Name:Contact Phone #/ Email Address: ................
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