• Current SECTION 1: Facility Information
  • SECTION 2: Personal Protective Equipment Request
  • Complete

Requestor Authorization:

  • I HEREBY CERTIFY THAT THE FACILITY BELOW IS TAKING ALL NECESSARY AND APPROPRIATE MEASURES TO CONSERVE PPE IN BOTH CURRENT SUPPLY AND REQUESTED ALLOCATION ACCORDING TO CDC GUIDANCE.
  • I HEREBY CERTIFY THAT THE FACILITY WILL NOT CHARGE FOR PPE OR OTHER SUPPLIES RECEIVED FROM THE STATE OF MARYLAND OR LOCAL HEALTH DEPARTMENT (EITHER DIRECTLY OR THROUGH A THIRD-PARTY PAYER, SUCH AS INSURANCE).
  • I HEREBY CERTIFY THAT THE FACILITY HAS EXHAUSTED ALL OTHER MEANS OF OBTAINING PPE, TO INCLUDE THE COMMERCIAL SUPPLY CHAIN AND FEDERAL RESOURCES (E.G. DIRECT CARES ACT FUNDING.)
  • I UNDERSTAND THAT THE FACILITY MAY NOT RECEIVE THE TOTAL AMOUNT OF SUPPLIES REQUESTED.

If you have any questions please email us at CountyEOC@co.pg.md.us and/or kmstinchcomb@co.pg.md.us.

Facility Address
Facility Type

First and last name