Clinical Coordinator's Name *

Clinical Coordinator's Department *

Clinical Coordinator's Email *

This PPE request is for: *
- Select Option An Individual Student A Group, Cohort, or Class

Please provide the number of individuals who need PPE in this group, cohort, or class: *

Please provide the Course Number & Section Number(s) associated with this clinical placement: *

PPE Distribution Method: *
- Select Option The student will pick-up the requested PPE supplies on the Health Campus A designated department contact will need to pick-up the supplies and distribute the supplies to the student.

Student's Name *

Student's Email (The student will be contacted at this email to coordinate pick-up of this PPE request) *

Student's Email *

Designated Department Contact's Name on the Health Campus (who will distribute PPE to the student): *

Designated Department Contact's Email *
Please enter a GVSU email address ending in @gvsu.edu or @mail.gvsu.edu.

Designated Department Contact's Name on the Health Campus (This person will be contacted for the delivery of this PPE request & must confirm when supplies are received) *

Designated Department Contact's Email *
Please enter a GVSU email address ending in @gvsu.edu or @mail.gvsu.edu.

What date is the requested PPE required? *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2020 2021 2022 2023 2024 2025

Clinical Site Name *

Copy & Paste a statement from the clinical site verifying what PPE & quantity is required at their site. Please include a contact name & date of correspondence. *

Please click on the items below that are required for this clinical site. Once you select an item you will be prompted to type in the quantity of each item that is needed. *
Face Shields
Safety Glasses
Safety Goggles
Cloth Masks
3-Ply Procedure Masks
Isolation Gowns
N95 Masks
Surgical Gowns, Medium
Surgical Gowns, Large
Surgical Gowns, X-Large
Shoe Covers/Booties
Bouffant Caps
Neoprene Surgical Gloves, Size 7
Neoprene Surgical Gloves, Size 8
Neoprene Surgical Gloves, Size 9

Quantity of Face Shields Required: *

Quantity of Safety Glasses Required: *

Quantity of Safety Goggles Required: *

Quantity of Cloth Masks Required: *

Quantity of 3-Ply Procedure Masks Required: *

Quantity of N95 Masks Required: *

Quantity of Isolation Gowns Required: *

Quantity of Medium Surgical Gowns Required: *

Quantity of Large Surgical Gowns Required: *

Quantity of X-Large Surgical Gowns Required: *

Quantity of Shoe Covers/Booties Required: *

Quantity of Bouffant Caps Required: *

Quantity of Neoprene Surgical Gloves, Size 7 Required: *

Quantity of Neoprene Surgical Gloves, Size 8 Required: *

Quantity of Neoprene Surgical Gloves, Size 9 Required: *