H5N1 Farms: Personal Protective Equipment Resource Request

As recommended by the federal Centers for Disease Control & Prevention (CDC) to protect against bird flu, the California Department of Public Health (CDPH) and the California Department of Food and Agriculture (CDFA) are working together to support a one-time distribution of​ personal protective equipment (PPE) for dairy farmworkers and others who handle raw milk, as well as slaughterhouse and poultry farm workers. Farms, businesses, and organizations that employ or serve dairy farmworkers, workers who handle raw milk, and slaughterhouse and poultry workers can order a ONE-TIME supply of Personal Protective Equipment (PPE), including the following:​​


N95 Masks

Gloves

Goggles

Face Shields

Bouffant caps ​​

Input the date that this form is being completed

Who is submitting this request?

Phone

Facility Information

Facility in need of supplies

Select or enter value
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Please indicate business/organization that employ or serve dairy farmworkers, workers who handle raw milk, and slaughterhouse and poultry workers.

Phone

Request Details

Number of employees in need of PPE at your facility.

Please advise that this date will remain tentative until a San Bernardino County Department of Public Health representative speaks with the provided Point of Contact to coordinate and confirm services.

Please advise quantities requested will be evaluated and adjusted based on current inventory supply and demand. Thank you for understanding.


Select all that apply.

Please indicate the size needed. Select all that apply.

Indicate total number of pairs of gloves needed. (i.e. 20 pairs)

Indicate total number of pairs of gloves needed. (i.e. 20 pairs)

Indicate total number of pairs of gloves needed. (i.e. 20 pairs)

Indicate total number of pairs of gloves needed. (i.e. 20 pairs)

Indicate quantity needed.

Indicate quantity needed.

Indicate quantity needed.

Indicate quantity needed.

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