South Dakota Department of Health PPE Supply RequestForm ...
South Dakota Department of Health PPE Supply RequestForm
COVID-19 Response Activities Only
Name: ________________________________________________________________________________
Facility/Agency:_________________________________________________________________________
Shipping Address:_______________________________________________________________________
Email Address:__________________________________________________________________________
Direct Phone Number to the person requesting?_______________________________________________
Are you following CDC Guidance for PPE? ___ Yes ___ No
Items requested:
Quantity
Item
Have you contacted multiple Vendors who were unable to fill/ partial fill/ cancel/ deny order supplies and/equipment? ____Yes ____ No
Anticipated date of Critical Need? _______/ ________ / _________
Email to: COVIDResourceRequests@state.sd.us Fax to: 605.773. 5942 If you have questions please call: 605.773.3048
PPE Supply Request Form. Revised Date: March 17, 2020
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