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Community Organization Resource Requests
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Date of Request
Name of Requesting Facility
Address of Facility (DUPAGE COUNTY ONLY)
City
State
Zip Code
Point of Contact (POC) Name
POC Email Address
Phone Number
***PLEASE INCLUDE TOTAL COUNTS YOU WOULD LIKE TO REQUEST RATHER THAN A BOX/CASE COUNT
Item Requested
iHealth COVID-19 Antigen Tests
Quantity Requested
Item Requested
KN95 Masks
Quantity Requested
What population(s) do you plan to redistribute these resources to? (e.g., staff, patients/clients, etc.)
Is your organization currently in need of any other Personal Protective Equipment (PPE)? If so, please describe the item(s) below.
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