PPE Request for Businesses PPE Request for Businesses Survey Questions PPE Request for Businesses Survey Questions If you are a company that would like to be included in the database, please fill out the following: Name: * Company Name: * Phone * Email * What is your current product? * What product would you like to provide? If you are unsure of what is needed, select below. Willing to help Unsure how Who would be your customers? How long will it take to deliver new product? How much can you provide? Please add any relevant notes, questions or challenges. Would you like to be featured on a list of business resources available for coronavirus support? * Yes No If you are in need of a specific good or service, please fill out the following: What do you need to procure? Surgical masks Hand sanitizer Plastic Gloves Hospital Gowns N95 Masks Protective Eye Goggles Face Shield Ventilators If other need to procure, please explain: How many do you need? What do you typically pay per unit? Is there a price range? Would you like to co-procure this product with another local health care provider to potentially lower the price point? Yes No What organization to you represent? Or the name of the organization that is in need? * Name? * Phone number? * Email? * Submit If you are human, leave this field blank.