Appointment and Resource Request Form

Appointment and Resource Request Form

For Employee Use ONLY

PLEASE ALLOW 2 BUSINESS DAYS FOR REQUEST TO BE FULFILLED. A CONFIRMATION EMAIL WILL BE SENT ONCE AVAILABLE FOR PICK UP.

Date Supplies Needed By*

Pick-up Appt request date

Appt Time Request*

Select or enter value

Requested By Name*

Requested by Email*

Include full email with ...@csusm.edu

CSUSM Affiliation*

Select

CSUSM Division*

(Requesting Department)

Select

CSUSM Department*

Resource Requested*

Select

Available only for close contacts

Available only for close contacts identified by CSUSM Covid-19 Case Management Team (CCMT).

Order Quantity*

Order Quantity (KN95 mask)*

Order Quantity (N95 masks)*

I have read the information on N95 respirators for COVID-19 Prevention.*

I have read the training document for N95 respirator voluntary use.*

Comments or Special Requests*

Reason for CPE/PPE request for larger orders (for satellite locations)

Send me a copy of my responses