Hospital Questionnaire

MaskGrant PPE Request Form:

Submit a request for PPE below and our team will try to match you with grants as quickly as possible.

What is your full name?

What is your title?

What is your email address?

What is your phone number?

What is the name of your institution/hospital?

What is the institution/hospital shipping street address?

What is the institution/hospital shipping city?

What is the institution/hospital shipping state?

What is the institution/hospital shipping zip code?

What is the institution/hospital website?

Does this hospital accept donations?

Name of the Purchase Director of the instition?

Email address or phone number Purchase Director?

What type of masks are needed? (Medical, N95, KN95, Surgical)

What other supplies are needed? (Surgical Gloves, Isolation Gowns, Protective Goggles, Coveralls, Face Shields?)

Would you be open to receiving free lunch from a local restaurant to celebrate you?

Yes, that would be great!

No, maybe next time.

Thank you. Your information has been submitted!