V 5.0 5/19/2020
Personal Protective Equipment Resource (PPE) Request – Effective 5/20/2020
Personal Protective Equipment (PPE) from the State-sourced cache is available to organizations and agencies involved in the
COVID-19 response in Trauma Service Area E based on critical need. Please read the following and fill in all requested
information if use of this form or through links below is deemed appropriate.
Essential Information
Organizations experiencing a critical shortage of PPE necessary for COVID-19 response may request supplies from the
State-sourced PPE cache.
The State-sourced PPE cache is not intended to replace commercial vendor PPE sources.
PPE will not be distributed on a first-come-first-serve basis, but will be based on critical need.
Availability of State-sourced PPE supplies will determine what requests may or may not be filled at any given time.
Requesting PPE from the State-sourced cache
To request Personal Protective Equipment (PPE) from the State-sourced cache, follow the steps below.
• If you are a Hospital, Other Healthcare Provider, or Agency/Organization that experiences COVID-19 positive encounters
or supports vulnerable populations, you may submit your request through the NCTTRAC web link:
https://ncttrac.org/covid-19-ppe-request-form/
o If you are unable to access the above link, fill out this form and submit it to your city or county’s Office of Emergency
Management who will submit it to the State of Texas Assistance Request (STAR) system.
• If you are a Private Practice Physicians Office, rather than use this form, submit your request through the Texas Medical
Association’s COVID-19 Help page at the following link: https://www.texmed.org/ (TMA membership not required, but login
registration is). For questions, contact the TMA Knowledge Center via email at knowledge@texmed.org or call (800) 880-7955.
The second page of this document illustrates PPE supply items that NCTTRAC is generally providing from the State-sourced cache. If
desired items are not identified on Page 2, a separate request will need to be submitted through your city or county’s Office of
Emergency Management who will submit it to the State of Texas Assistance Request (STAR) system. We will contact your
organization within 72 hours if we are able to fill/partial fill your request. Requestor may resubmit after 72-96 hours if PPE quantity
or item is unable to be obtained via their normal procurement methods, or sooner if an emergency.
Entity Name: _____________________________________________________ Entity HHSC/DSHS License #: ___________________
Entity Type: Assisted Living Facility Behavioral Health Clinic/Physician Office DADS/State Facility (SSLC)
Dialysis EMS/EMT/Medic Freestanding ER Home Health
Hospice Hospital Nursing Home Public Health
Medical Examiner/Morgue/Funeral Home Other _______________________________________________
Entity Address (Street, City, County): ______________________________________________________________________________
Requestor Name: ____________________________________ Requestor Title: _________________________________________
Requestor Phone #: __________________________________ Requestor Email: ________________________________________
Authorized Pick-Up Person (Must match name on Driver’s License)
Name: ____________________________________________ Title: ___________________________________________________
Phone #: __________________________________________ Email: ___________________________________________________
