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2. Please complete this form if you are in need of Personal Protective Equipment (PPE)/or disinfectant supplies for the COVID-19 Response. **Please note that requests will only be reviewed/filled for affiliates of New Kent County. Requests should only be submitted under the direction of Department Heads.
4. Requests should be submitted weekly on Mondays by close of business. Requests will be evaluated/fulfilled on a weekly basis unless indicated as 'Urgent' priorty.
6. Request Date*
   Request Date

   Request Date
8. Facility/Department Name*
   -- Select One --Bay TransitBoard of EqualizationBuilding Development/PermitsChamber of CommerceCircuit CourtCommissioner of RevenueCommonwealth Attorney's OfficeCounty AdministrationCounty AttorneyCourt ServicesCSA Office ( Office of Child Services)DMVEconomic DevelopmentEnvironmentalFinanceGeneral District CourtGeneral ServicesGISHenrico Jail EastHuman ResourcesInformation TechnologyJuvenile & Domestic CourtNew Kent AirportOtherParks & RecreationPlanningPublic UtilitiesRappahannock Community CollegeSchool Board OfficeSchools - GW Watkins ESSchools - NKESSchools - NKMSSchools - NKHSSchools - Bridging CommunitiesSchools - MaintenanceSchools - Student ServicesSchools - TransportationSheriff's OfficeSocial ServicesThrive VirginiaTreasurer's OfficeVirginia Cooperative ExtensionVictim/Witness AssistanceVoter Registration

   Indicate your department. If you do not see your department listed, select other and enter facility/Department
9. Facility/Department Address*
   This should be an address where supplies can be delivered.
11. Facility/Department Other:*
15. Requestor Name*
16. Requestor Email*
18. Requestor Primary Phone #*
    Format: ###-###-####
19. Requestor Secondary Phone #
    Format: ###-###-####
21. Request Priority*

    Urgent: Immediate Need. High Priority: Out of Supplies/Running out in 1-7 days Medium Priority: Running out of supplies in 8-14days Low: Running out of supplies in 15-30 days

    1. Urgent

    1. High Priority

    1. Medium Priority

    1. Low Priority
23. Items being Requested*

    Please indicate which items you are requesting.

    1. N95 Masks(Fire/EMS/Law Enforcement Only)
    2. Surgical Masks
    3. Gloves
    4. Gowns
    5. Goggles/Face Shields

    1. Hand Sanitizer
    2. Disinfectant Wipes
    3. Disinfectant Spray
    4. Thermometer(s)
    5. Other(please specify in comments)
27. N95 Masks used/day
    Enter average number of N95 masks used per day.
28. N95 Masks On Hand
    Quantity of N95 Masks currently On Hand.
29. N95 Requested
    Quantity N95 Requested.
31. Surgical Masks used/day
    Enter average number of surgical masks used per day.
32. Surgical Masks On Hand
    Quantity of masks currently On Hand.
33. Surgical Masks Requested
    Quantity Surgical Masks Requested.
35. Gloves used/day(pairs)
    Enter the average number of gloves used per day (in pairs).
36. Gloves On Hand (pairs)
    Quantity of gloves currently On Hand (in pairs).
37. Gloves Requested
    Quantity of Gloves Requested.
39. Gowns used/day
    Enter average number of gowns used per day.
40. Gowns On Hand
    Quantity of gowns currently On Hand.
41. Gowns Requested
    Quantity of gowns requested.
43. Goggles/Face shields used/day
    Enter average number of goggles/face shields used per day.
44. Goggles/Face Shields On Hand
    Quantity of Goggles/Face Shields On Hand.
45. Goggles/Face Shield Requested
    Quantity of goggles/face shields requested.
47. Hand Sanitizer used/day
    Enter average number of hand sanitizer used/day.
48. Hand Sanitizer On Hand
    Quantity of Hand Sanitizer On Hand.
49. Hand Sanitizer Requested
    Quantity of Hand Sanitizer Requested.
50. Hand Sanitizer Units

    Choose a unit of measurement.

    1. Gallon
    2. Hand Pump
    3. Personal
52. Disinfectant wipes used/day(containers)
    Enter the average number of containers of disinfectant wipes used per day.
53. Disinfectant wipes On Hand(containers)
    Quantity of disinfectant wipes containers on hand.
54. Disinfectant wipes requested(containers)
    Quantity of disinfectant wipes requested(containers).
56. Disinfectant Spray/day
    Enter the average bottles of disinfectant spray used per day.
57. Disinfectant Spray On Hand
    Quantity of Disinfectant Spray On Hand.
58. Disinfectant spray Requested
    Quantity of Disinfectant spray bottles requested.
60. Thermometer(s) on Hand
    Enter the number of thermometer(s) on hand
61. Thermometer(s) Requested
    Enter the number of thermometer(s) requested.
63. Comments/Additional Needs:
    Please provide any comments/additional needs not addressed in this request.
64. Request Justification:*
    Please provide brief justification for your requests.
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field