PPE Request Form

Personal Protective Equipment

for organizations supporting health & wellness in King County, WA

Purpose

Please submit the following form to request a supply of personal protective equipment (PPE) for your organization and/or the people you serve. Orders are free of charge, courtesy of the partnership between HealthierHere and the WA State Health Care Authority (HCA).

Click here to preview the list of items that you may request.

Eligibility

Health and social service organizations that serve King County, WA residents may request PPE using this form. HealthierHere partners are encouraged to submit requests; however, your organization does not need to be a current partner to use this form and receive PPE. You must be able to arrange pick-up of all ordered PPE (see Pick Up below for more info).

Schedule

We encourage organizations to request 1-2 months' worth of supplies per order. We anticipate submitting orders each Thursday. Orders not received by 8am Thursday will be included in the following week's order unless you contact us to make other arrangements.

Pick Up

All orders will require in-person pick-up from the Ballard neighborhood in northwest Seattle, WA. We will contact you to arrange pick up details. All people present at the time of pick up must wear face coverings and take appropriate precautions to prevent the spread of COVID-19.

We are unable to offer delivery at this time.

My Contact Info

"I have the authority to enter this form on behalf of my organization, and I agree and attest to the best of my knowledge that the information below is true and correct. I understand that my organization is responsible for picking up our order from Seattle. My organization will not resell the items requested in this form." (Required)

First Name

Last Name

Phone

Note: Does not need to match the person who will pick up the order (we will contact you to arrange pick up details).

My Organization

Organization Name

Do you serve King County residents?

YesNoWe are only able to supply health and social service organizations serving King County. For assistance in other WA counties, please contact your local Accountable Community of Health: washingtonach.org/contact

Our organization is a (select all that apply):

Community-Based Organization or CoalitionBehavioral Health AgencyTribal Health Care ProviderFederally Qualified Health CenterHospital or Health SystemNone of the above

Please describe:

This data will be used to track orders and distribution, and to help assess needs.

My Order

Instructions:

Please order each item in "eaches." i.e., Do not request boxes, cases, etc. as these vary by manufacturer
Please indicate if substitutions may be made if an item is out of stock.

You may also click here to preview the list of items that you may request..

I want to order gloves

YesNo, skip gloves

GLOVES

IMPORTANT: Please enter the number of INDIVIDUAL GLOVES requested (e.g., if you request 100 gloves, you will receive 50 pairs)

Gloves, Nitrile, Small

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gloves, Nitrile, Medium

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gloves, Nitrile, Large

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gloves, Nitrile, X-Large

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

I want to order gowns

YesNo, skip gowns

GOWNS

Gowns, Disposable, Small, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, Medium, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, Large, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, X-Large, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, XX-Large, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, One Size, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, Small, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, Medium, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, Large, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, X-Large, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, XX-Large, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Gowns, Disposable, One Size, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

I want to order face coverings

YesNo, skip face coverings

FACE COVERINGS

Respirator Mask, KN95

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Respirator Mask, KN95 with Ear Loops

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Respirator Mask, KN95 with Neck Strap

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Respirator Mask, KN95 with valve

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Masks, KN95, Small

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Cloth Protective Face Covering (i.e. Cloth Mask)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Child sized Cloth Protective Face Covering (i.e. Cloth Mask)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Procedure Mask, Level 1

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Procedure Mask, Level 2

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Procedure Mask, Level 3

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Child Sized Procedure Mask

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Respirator Fit Test Kit

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Respirator Fit Test Solution (Bittrex/Bitter)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Respirator Fit Test Solution (Saccharine/Sweet)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

I want to order body coverings

YesNo, skip body coverings

BODY COVERINGS

Coveralls, Tyvek, Medium

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Coveralls, Tyvek, Large

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Coveralls, Tyvek, X-Large

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Coveralls, Tyvek, XX-Large

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Coveralls, Tyvek, XXX-Large

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Plastic Aprons

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Safety Goggles

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Safety Glasses

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Face Shield

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Medical Caps, Blue (Bouffant)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Shoe/Boot Covers

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

I want to order cleaning/sanitation supplies

YesNo, skip cleaning/sanitation supplies

CLEANING & SANITATION SUPPLIES

Cleaning Solution Spray

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Disinfectant Spray

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Hand Sanitizer, Liquid (generally 1 gallon)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Hand Sanitizer, Gel (generally 16.9 oz)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Cleaning/Disinfecting Wipes

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

Cavicide Wipes

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

I want to order powered air purifying respirators

YesNo, skip powered air purifying respirators

POWERED AIR PURIFYING RESPIRATOR (PAPR)

PAPR Kit (Belt, Filter, Hood, Charger)

Quantity requested

Is a substitution acceptable?

YesNo

Please indicate acceptable substitutions

PAPR Other (Please Specify)

Quantity requested

Please specify:

Please review your request and click the Submit button below.

By clicking Submit, I verify that I have read, understood and agreed to the following:

HealthierHere is facilitating this distribution/donation as a public service. HealthierHere does not provide medical advice; nor can HealthierHere guarantee these items. HealthierHere has not and will not accept any payment by sharing this information or providing this donation opportunity. This form is for informational purposes only and does not guarantee fulfillment.

You will receive a copy of your request at the email address entered above. HealthierHere staff will contact you to arrange pick up and if there are any questions about your request.

reCAPTCHA helps prevent automated form spam.

The submit button will be disabled until you complete the CAPTCHA.

Questions about ordering PPE via HealthierHere? Please Email Us

Need technical assistance using this page/form? Contact Melissa by email or 206.486.9339.

Personal Protective Equipment

for organizations supporting health & wellness in King County, WA

PPE Request Form

About

Our Work

Our Impact

Our Committees

News & Resources

Get Involved

Questions? Send us a message >>

No Upcoming Events