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PA Critical Donations Portal




* Denotes a required field
Please note all text boxes in this form are limited to 500 characters. Please provide additional information as attachments, if necessary.
Attachments added are shown at the bottom of the page.

Donor Organization Name *
Donor Organization Website
Country of Donor *
Address
City
State
Zip
Non US Address
Donation Point of Contact First Name *
Donation Point of Contact Last Name *
Donation Point of Contact Email *
Confirm Email *
Donation Point of Contact Phone # *
Commonwealth of PA Supplier?
Vendor Number
What is the donation type? *
PPE Donation Description
Meets ASTM Levels 1-3 or FDA Approved
GF_ASTM_TotalItemsAvailable
GF_ASTM_IsTheProductNew
GF_ASTM_DateAvailable
GF_ASTM_ProductCountryOfOrigin
Surgical_Unknown
GF_FDA_TotalItemsAvailable
GF_FDA_IsTheProductNew
GF_FDA_DateAvailable
GF_FDA_ProductCountryOfOrigin
US: N100, P100, R100 N99, N95, P95, R95
GF_USN100_TotalItemsAvailable
GF_USN100_IsTheProductNew
GF_USN100_DateAvailable
GF_USN100_ProductCountryOfOrigin
Australia: P2, P3
GF_Australia_TotalItemsAvailable
GF_Australia_IsTheProductNew
GF_Australia_DateAvailable
GF_Australia_ProductCountryOfOrigin
Brazil: PFF3, PFF2, KN100, KP100, KN95, KP95
GF_Brazil_TotalItemsAvailable
GF_Brazil_IsTheProductNew
GF_Brazil_DateAvailable
GF_Brazil_ProductCountryOfOrigin
China: KN100, KP100, KN95, KP95
GF_China_TotalItemsAvailable
GF_China_IsTheProductNew
GF_China_DateAvailable
GF_China_ProductCountryOfOrigin
Europe: FFP3, FFP2
GF_Europe_TotalItemsAvailable
GF_Europe_IsTheProductNew
GF_Europe_DateAvailable
GF_Europe_ProductCountryOfOrigin
Japan: DS/DL3, DS/DL2
GF_Japan_TotalItemsAvailable
GF_Japan_IsTheProductNew
GF_Japan_DateAvailable
GF_Japan_ProductCountryOfOrigin
Korea: Special 1st
GF_Korea_TotalItemsAvailable
GF_Korea_IsTheProductNew
GF_Korea_DateAvailable
GF_Korea_ProductCountryOfOrigin
Mexico: N100, P100, R100, N99, N95, P95, R95
GF_Mexico_TotalItemsAvailable
GF_Mexico_IsTheProductNew
GF_Mexico_DateAvailable
GF_Mexico_ProductCountryOfOrigin
Unknown
GF_IDontKnow_TotalItemsAvailable
GF_IDontKnow_IsTheProductNew
GF_IDontKnow_DateAvailable
GF_IDontKnow_ProductCountryOfOrigin
FDA Certificate Number
Without Impenetrable Foam Barrier
GF_Minimum_TotalItemsAvailable
GF_MInimum_IsTheProductNew
GF_Minimum_DateAvailable
GF_MInimum_ProductCountryOfOrigin
With Impenetrable Foam Barrier
GF_Impenetrable_TotalItemsAvailable
GF_Impenetrable_IsTheProductNew
GF_Impenetrable_DateAvailable
GF_Impenetrable_ProductCountryOfOrigin
GF_PaperMasks_ProductCountryOfOrigin
Medical Grade Alcohol Based Hand Rub
GF_EthylAlcohol_TotalItemsAvailable
GF_EthylAlcohol_IsTheProductNew
GF_EthylAlcohol_DateAvailable
GF_EthylAlcohol_ProductCountryOfOrigin
Aprons
GF_Aprons_TotalItemsAvailable
GF_Aprons_IsTheProductNew
GF_Aprons_DateAvailable
GF_Aprons_ProductCountryOfOrigin
Contains Latex?
GF_Latex_TotalItemsAvailable
GF_Latex_IsTheProductNew
GF_Latex_DateAvailable
GF_Latex_ProductCountryOfOrigin
Contains Nitril?
GF_Nitril_TotalItemsAvailable
GF_Nitril_IsTheProductNew
GF_Nitril_DateAvailable
GF_Nitril_ProductCountryOfOrigin
Contains Rubber?
GF_Rubber_TotalItemsAvailable
GF_Rubber_IsTheProductNew
GF_Rubber_DateAvailable
GF_Rubber_ProductCountryOfOrigin
Goggles
GF_Goggles_TotalItemsAvailable
GF_Goggles_IsTheProductNew
GF_Goggles_DateAvailable
GF_Goggles_ProductCountryOfOrigin
Fluid Resistant
GF_FluidResistant_TotalItemsAvailable
GF_FluidResistant_IsTheProductNew
GF_FluidResistant_DateAvailable
GF_FluidResistant_ProductCountryOfOrigin
Protective Suits
GF_ProtectiveSuits_TotalItemsAvailable
GF_ProtectiveSuits_IsTheProductNew
GF_ProtectiveSuits_DateAvailable
GF_ProtectiveSuits_ProductCountryOfOrigin
Sanitizing Wipes
GF_SanitizingWipes_TotalItemsAvailable
GF_SanitizingWipes_IsTheProductNew
GF_SanitizingWipes_DateAvailable
GF_SanitizingWipes_ProductCountryOfOrigin
Other PPE
Other
DOH Approved
Donation Received by
Donation Form Signed
Donor Identifiable Shipment Number
Delivery Date
Shipment size
Person Entering Info
Date Entered
Confirmation of receipt of items
PF_Status
Direct to County or Local Facility
Donation complete
wfbit
wfstatus
Attachments