I/DD Consultation Form

Urgent Consultation Request Form

Service providers operating I/DD Group Homes. Please use this form only to request a consultation for emergent/urgent needs related to COVID-19 outbreak, critical PPE shortage, etc.

* Indicates required field

Is this an urgent/emergent request? *

Yes No

(This form is for urgent/emergent needs only. If you said "No" to the question above, please contact PCC by regular e-mail)

What is the nature of the request? *

Please provide details to explain the request (do not include any protected health information (PHI). *

Name of Organization *

Contact Name *

First

Last

Location *

Line 1

Line 2

City

State

Zip Code

Country

In a 24 hour period, how many staff work at the affected site? *

At the affected site, how many staff do personal care? *

How many times per day will they be in close contact with residents? *

At the affected site, what is the total number of residents who can wear a mask? *

At the affected site, what is teh total number of residents needing personal care? *

Is your organization participating in the PPE Group Purchasing Program operated by PCC? *

Yes No

Due to a limited emergency stockpile PCC will only provide two weeks of PPE consistent with contingency strategy of use.

In the comments section, please give a concise explanation of your organizations plans to secure PPE to cover future needs. For example, if you have already ordered PPE and are waiting for supplies to arrive, please tell us that you have ordered PPE and when it is expected to be delivered. If retaining adequate amounts of PPE has been challenging for your organization, please note this in the comments section as well.

Organizations participating in the Group Purchasing program do not need to complete this section.

Plans to Secure PPE For Future Needs *

Contact Email *

Contact Phone Number *

Submit

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A copy of our current financial statement is available by contacting the Primary Care Coalition. Documents and information submitted to the State of Maryland under the Maryland Charitable Solicitations Act are available from the Office of the Secretary.