PPE & SUPPLIES EMPLOYEE REQUEST FORM

Please complete the form in its entirety. Requests should only be submitted by department heads or administrative assistants who have received prior approval from their department head.

Once your form is successfully completed, you will be contacted to confirm your order. Thank you.

Name of Requestor: *
Email: *
Office Phone Number: Office Phone Number: * - ### - ### ####
Alternate Phone Number: Alternate Phone Number: - ### - ### ####
Department: *
Department Head Contact Information: *
Date Requested: Date Requested: * / MM / DD YYYY
Location for Request:

Campus/Center
Building
Room for Delivery
Please Select the PPE/Supplies Desired
**Items are also located at each sanitation station at the entrance to each building and on every floor.
Face Shields (single count)

Face Shields (single count) Face Shields
Face Shields - Quantity *
Eye Shields (glasses) (single count)

Eye Shields (glasses) (single count) Eye Shields (glasses)
Eye Shields (glasses) - Quantity *
Gloves (box count) **

Gloves (box count) ** Gloves (box count) **
Glove Size

Glove Size Small Medium Large X-Large
Small Gloves - Quantity *
Medium Gloves - Quantity *
Large Gloves - Quantity *
X-Large Gloves - Quantity *
Adult Disposable Face Masks (box count) **

Adult Disposable Face Masks (box count) ** Adult Disposable Face Masks **
Adult Disposable Face Masks - Quantity *
Child Size Face Masks (box count )

Child Size Face Masks (box count ) Child Size Face Masks
Child Size Face Masks - Quantity *
Desktop Size Hand Sanitizer (single count)

Desktop Size Hand Sanitizer (single count) Desktop Size Hand Sanitizer
Desktop Size Hand Sanitizer - Quantity *
Desktop Size Disinfectant Wipes (single count)

Desktop Size Disinfectant Wipes (single count) Desktop Size Disinfectant Wipes
Desktop Size Disinfectant Wipes - Quantity *
Large Disinfecting Wipes (single count) for Classrooms, Labs, & Common Areas Only

Large Disinfecting Wipes (single count) for Classrooms, Labs, & Common Areas Only Large Disinfecting Wipes for Classrooms, Labs, & Common Areas Only
Large Disinfecting Wipes for Classrooms, Labs, & Common Areas Only - Quantity *
Large Disinfecting Wipes - Refill (single count)

Large Disinfecting Wipes - Refill (single count) Large Disinfecting Wipes- Refill
Large Disinfecting Wipes - Refill - Quantity *
Shield for Desks

Shield for Desks Shield for Desks
Shield for Tables & Counters

Shield for Tables & Counters Shield for Tables & Counters
Shield for Cubicle

Shield for Cubicle Shield for Cubicle
Other/Notes

Other/Notes Other/Notes
Other/Notes- Describe Below:

PPE & SUPPLIES EMPLOYEE REQUEST FORM

PPE & SUPPLIES EMPLOYEE REQUEST FORM

Please Select the PPE/Supplies Desired **Items are also located at each sanitation station at the entrance to each building and on every floor.

Please Select the PPE/Supplies Desired
**Items are also located at each sanitation station at the entrance to each building and on every floor.