PPE and Medical Supplies Request Form

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PPE and Medical Supplies Request Form

Please use this form to request 14 days’ worth of supplies for your facility. These orders will be transmitted to the state and filled to the extent possible. Once an order is filled, even partially, or if we are unable to fill your order, we will contact you and close the request for the week. You will need to resubmit a request for any unfulfilled orders.

See what supplies are currently on the request list

If you are requesting supplies for a school, click here to see a list of supplies available to your school. Please do not request supplies other than what is listed.

For items not on the list, please submit an RR213 form

This form is for facilities and agencies within King County only

This form is adapted from FEMA’s 213RR

Fields with an asterisk (*) and outlined in red are required.

Recipient facility

If you're completing a request on behalf of another facility, please enter that facility's name, not your own.

Recipient facility type

If you're completing a request on behalf of another facility, please select that facility's type, not your own.

Requester Information

Requester's full name

Requester's email

Requester's phone

Format: 555-555-5555 An extension after the number is allowed.

Facility Address (Street address)

Facility Address 2 (Optional suite or floor number, etc.)

City / town

Zip code

What are the hours of operations for your facility?

Is your facility able to receive deliveries after hours?

Yes

Is your facility able to receive deliveries on the weekend?

Yes

Delivery contact and location information

Information about to whom and where to deliver an order.

King County will not deliver supplies to a private residence. All delivery address must be a facility or business address.

Check this box if the delivery address is same as requester address.

Contact's full name

Contact's email

Contact's phone

Format: 555-555-5555 An extension after the number is allowed.

Delivery location information

(Address, GPS coordinates, important notes, etc.)

Request supplies

You can request up to 20 items with this form. If you need more, please complete another form.

If requesting items not in drop down, please complete the 213 form and email to rcecc.logs@kingcounty.gov.

1. What are you requesting?

Order quantity (By individual units, not pairs, boxes, etc.)

IMPORTANT: You must fill in the total number of individual units you want.

This must be a number.

Additional notes

NOTE: If you are a public health agency, please detail what you're requesting PPE for.

Date Items are Needed by

Priority

Life-saving - This includes rescuing endangered civilians, treatment of the injured, and provisions for the safety, accountability and welfare of response personnel.

Incident stabilization - To keep the incident from escalating and bring it under control to limit the negative consequences.

Property preservation - Protection of property, infrastructure, evidence, economy and the environment.

Is your facility/agency/program CURRENTLY treating, transporting, housing, or otherwise interacting with confirmed or presumptive cases of COVID19 in a way that requires personal protective equipment?

Yes

By submitting this request, your organization/agency is acknowledging willingness to pay for the assistance. If you have questions about funding, please email rcecc.finance@kingcounty.gov

ecc.kc@kingcounty.gov

206-296-3830
Toll Free 1-800-523-5044

TTY Relay 711

King County Emergency News

Last Updated February 19, 2021
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