Government of Alberta

Personal Protective Equipment (PPE) Request Form

    Instructions:

  • This PPE request form is divided into 3, please follow the instructions at the top of each section.
  • NOTES:
    • When requesting items by container, the number of product in a container may vary depending on availability (e.g. Lysol wipes 50 sheets, 250 sheets, etc.)
    • All requests will be reviewed based on Alberta Health PPE Guidelines and are dependant on availability.

Section 1: Basic Information on your agency, organization or business

  • Requests with incomplete mandatory fields (marked with an *) cannot be processed.

Request Date *

Select a date from the calendar.

Agency Type *


Agency Name *


Describe your Type of Agency
(Example: Shelter, Provides Meals,
Services Provided)
*


Requestor Name


Delivery Contact Name *


Requestor Phone Number


Delivery Contact Phone Number *


Requestor Email


Contact Email *


PPE Delivery Address Line 1 *


PPE Delivery Address Line 2 *


PPE Delivery City *


PPE Delivery Postal Code *


Section 2: PPE required for the COVID-19 specific response

  • PPE items requested in this section should be based on a quantity required for a TWO (2) WEEK need.
  • Local sources have been unable to obtain requested items.
  • Please refer to the PPE Guidelines and the Alberta Health Website to assist in the request for PPE.

Hand Sanitizing Disinfectant Liquid (Non-Alcohol Solution)


Hand Sanitizing Disinfectant Liquid (Solution)

Under 500mlOver 500ml2L Bulk



Hand Sanitizing Disinfectant Wipes


Disinfectant Surface Wipes (Lysol/Other)


Disinfectant Surface Wipes (Cavi)


Disinfectant Solution (Virox)

1 Litre2.5 litres4 litres



Surgical Masks


Disposable Gowns


Safety glasses/goggles


Gloves - Latex

XS

S

M

L

XL

2XL

Gloves - Non-Latex

XS

S

M

L

XL

2XL

Thermometers


Comments / Other:


Section 3: PPE required for daily usage

  • PPE items requested in this section should be based on a quantity required for a TWO (2) WEEK need.
  • PPE items in this section are required for daily use (meaning you required them before the COVID-19 Pandemic).
  • Local sources have been unable to obtain requested items.
  • A "Site Hazard Assessment" and/or justification for any requests in this section must be provided upon request.

Disinfectant Aerosol Cans


3M - N95

1860

8210

9210

1870

07048

1510

18602

62126 Duckbill Mask

8110

8110S

8200

8271

8511

9105

9105S

9211

A2320

FFP2

General

Medicom M2321

Pocket mask

RP723N95

Disposable Coveralls

Small

Medium

Large

XL

2XL

3XL

4XL

5XL

Tyvek Boot Covers


Disposable Aprons


Tyvek Sleeves


Face Shields


Cavicide


Respirator Cleaning Wipes


Comments / Other: