Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

New Kent County PPE Requests From County Partners

  1. 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.
  2. 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.
  3. This should be an address where supplies can be delivered.
  4. Format: ###-###-####
  5. Format: ###-###-####
  6. 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
  7. Items being Requested*
    Please indicate which items you are requesting.
  8. Enter average number of N95 masks used per day.
  9. Quantity of N95 Masks currently On Hand.
  10. Quantity N95 Requested.
  11. Enter average number of surgical masks used per day.
  12. Quantity of masks currently On Hand.
  13. Quantity Surgical Masks Requested.
  14. Enter the average number of gloves used per day (in pairs).
  15. Quantity of gloves currently On Hand (in pairs).
  16. Quantity of Gloves Requested.
  17. Enter average number of gowns used per day.
  18. Quantity of gowns currently On Hand.
  19. Quantity of gowns requested.
  20. Enter average number of goggles/face shields used per day.
  21. Quantity of Goggles/Face Shields On Hand.
  22. Quantity of goggles/face shields requested.
  23. Enter average number of hand sanitizer used/day.
  24. Quantity of Hand Sanitizer On Hand.
  25. Quantity of Hand Sanitizer Requested.
  26. Hand Sanitizer Units
    Choose a unit of measurement.
  27. Enter the average number of containers of disinfectant wipes used per day.
  28. Quantity of disinfectant wipes containers on hand.
  29. Quantity of disinfectant wipes requested(containers).
  30. Enter the average bottles of disinfectant spray used per day.
  31. Quantity of Disinfectant Spray On Hand.
  32. Quantity of Disinfectant spray bottles requested.
  33. Enter the number of thermometer(s) on hand
  34. Enter the number of thermometer(s) requested.
  35. Please provide any comments/additional needs not addressed in this request.
  36. Please provide brief justification for your requests.
  37. Leave This Blank:

  38. This field is not part of the form submission.