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COVID19 Emergency Requisition Request Form

The State Emergency Operations Center (EOC) has notified all healthcare entities to start assessing their immediate needs for Personal Protective Equipment (PPE) – N95, masks, gloves, sanitizer, suits. Resource requests should be a stop-gap measure to ensure the medical system continues to function. This is for your facility’s immediate needs, NOT strategic needs or maintenance of the immediate needs.

You must complete the updated State mandated COVID-19 Emergency Requisition Request Form. The State will deny requests when the Form is not appropriately completed.

Please provide TWO (2) points of contact (Primary & Alternate), one of these must be the individual who would be receiving the resource. You must provide TWO (2) phone numbers and an email address for each point of contact provided.
  • Primary Name
  • Primary Telephone (1)
  • Primary Telephone (2)
  • Primary Email Address
  • Alternate Name
  • Alternate Telephone (1)
  • Alternate Telephone (2)
  • Alternate Email Address
Please provide delivery address and any special information for delivery.

Please make sure of the following:
  • All fields of the form are complete before submitting
  • The box at the bottom of the form is checked
  • The form is signed
  • The above contact information is complete
  • A location for delivery is included

Once the COVID-19 Emergency Requisition Request form has been completed, please submit form to