COVID-19 Resource Request Form

Use this form to request COVID-19 related resources. The DC Department of Human Services is working closely with The Community Partnership to help facilitate access to critical supplies needed to keep customers and staff safe during this health emergency, in line with current CDC guidance. Please note that our ability to accommodate your request (items, quantity, brand preference etc.) is dependent on the availability of requested items. Allow up to two business days for a response. If you have questions about the status of your order or the items received please contact Jasmine Wardrick at jwardrick@community-partnership.org

Requesting Organization

Organization*

Please select the name of the organization requesting these supplies. If your organization is not on this list, select "Other" and fill in below.

Select or enter value

Other Organization

If you selected "Other" above, write in here. Otherwise, skip this field.

Type of Organization*

Please indicate if you are a provider contracting directly w/DHS, a TCP Sub-contractor, or a Community Partner.

Provider Contracting Directly w/DHS

TCP Sub-contractor

Community Partner

Program Type*

What services does the organization provide?

Select or enter value

Other Program Type

If you selected "Other" above, describe program type in here. Otherwise, skip this field. Example: "Food service"

Contract Administrator/Grant Administrator

For Providers Contracting Directly with DHS: Please enter the name of your Contract or Grant Administrator here. Example: Jane Smith; jane.smith@dc.gov

Supplies

Urgency*

Urgency Levels: High - critical operations will cease if supplies not received within 72 hours Medium - resource needed and currently in short supply Low - long-term need exists but resource is currently in stock

High

Medium

Low

Supplies Requested*

What supplies are you requesting? Select all that apply.

Select or enter value

Other Supplies

If you selected "Other" above, provide a description of the supplies you are requesting here. Otherwise, skip this field.

Supplies Description

Please provide a short title description of the items you are requesting limited to a few words, such as "cleaning wipes".

Preferred Items*

If applicable, paste internet link to an example of the items you want, from any vendor, in text box below.

Initial Quantity Ordered*

List supplies and the desired quantity for each supply ordered. NOTE: Be specific! Enter an amount and description, then hit enter to move to a new line before entering the next description. Example: 200 pairs of exam gloves, medium size 20 individual bottles of hand sanitizer, 8 oz 5 containers of disinfectant wipes, 80 wipes each

Packaging*

If needed, include packaging requirements. Example: "300 medical grade exam gloves in boxes of 100 or less"

Acceptable Alternative*

If we do not have the product that you are searching for, what would be an acceptable alternative?

Background Information

Describe the Intended Purpose/Use*

Be specific about the need, purpose, and justification. Example: "We need approved hand sanitizer for five dispensers in common areas of high-congregate facility"

Has Item Been Requested From Another Source?*

Let us know if you have ordered this from a vendor, requested the resource from TCP or another organization, etc.

Yes

If you did request it, were you able to obtain it?*

Contact & Delivery

Delivery Address*

List the address where supplies need to be delivered. NOTE: Write the name of the receiving organization, the street address, the city, and the zip code. Hit enter to move to another line. Example: Local Provider Attn: John Doe, Operations Manager 1234 Friendship Ave, NE Suite 200 Washington DC, 12345

Point of Contact Name*

Point of Contact Cell*

Point of Contact Email*

Comments*

If you have any additional comments or information that needs to be provided and was not covered in the form above, include here. If there is no additional information required, type "N/A".

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