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EOC PPE Request Form

Contact Information
Please tell us how we can reach you
Name*
First Last
Phone*
Email*
Select your Division*
Explain*
What department are you with?*
What PPE Do You Need?
Please identify the Personal Protective Equipment (PPE) needed. Due to current PPE supply shortages, please only identify 2-4 weeks of supply.
Surface disinfectant (Wipes or Spray)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Disposable gown (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Facemask/procedure mask (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Faceshield – Disposable (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Faceshield - Reusable (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Gloves XS - XL (BOX)
Gloves have now been moved to the MDS Corestock catalog on Shop@UW. These items will vary in brand but are no cost to the consumer. Use this guide to search for these gloves.
Hand Sanitizer (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
N95 respirator (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Tyvek suit/coverall – S (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Tyvek suit/coverall – M (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Tyvek suit/coverall – L (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Tyvek suit/coverall – XL (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Tyvek suit/coverall – XXL (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Tyvek suit/coverall – 5X (Each)
**Please do not use parentheses**
Quantity Description/What kind are you looking for?
Other
**Please do not use parentheses**
Item Name Quantity Description/What kind are you looking for?
Tell us about this request
How many employees will be using the requested items?*
How many weeks does this supply request represent?*
- <1 Week
- 1-2 Weeks
- 3-4 Weeks
- 4+ Weeks
Is the PPE required for an existing essential campus function?*
- Yes
- No
Is the PPE required for a new COVID-19 related task?*
- Yes
- No
Is this PPE required for research activities authorized by the Dean of your organization to continue during the period of limited campus operations?*
- Yes
- No
Describe use for PPE: (ex. Animal care, Research, Patient care, Custodial, etc.)*
Urgency of this request*
- Emergency (No supply on hand)
- Urgent (1-2 weeks on hand)
- Routine (2-4 weeks on hand)
- Low (4+ weeks on hand)
Where should it be shipped to?
Shop@UW MD Number (if known)
This Shop@UW account number will be used to place the order for PPE supplies
Building Name*
Shipping Contact Name*
First Last
Shipping Contact Phone
Shipping Contact Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Email: ShopUW@bussvc.wisc.edu
Phone: (608) 497-4400

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