Indiana Hospital Association Demand Assessment

1. Please enter the name of your hospital *This question is required.

2. Please enter your email address. *This question is required.

How many boxes of examination gloves do you need? *This question is required. This question requires a valid number format.

boxes of gloves

By what date do you need those boxes of gloves? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many isolation gowns do you need? *This question is required. This question requires a valid number format.

isolation gowns

By what date do you need those isolation gowns? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many surgical gowns do you need? *This question is required. This question requires a valid number format.

surgical gowns

By what date do you need those surgical gowns? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many N95 masks do you need? *This question is required. This question requires a valid number format.

N95 masks

By what date do you need those N95 masks? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many surgical masks do you need? *This question is required. This question requires a valid number format.

surgical masks

By what date do you need those surgical masks? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many face shields do you need? *This question is required. This question requires a valid number format.

face shields

By what date do you need those face shields? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many goggles/protective eyewear do you need? *This question is required. This question requires a valid number format.

goggles/protective eyewear

By what date do you need those goggles/protective eyewear? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many 1 gallon units of hand sanitizer do you need? *This question is required. This question requires a valid number format.

1 gallon units of hand sanitizer

By what date do you need those units of hand sanitizer? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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How many boxes of surface disinfectant wipes do you need? *This question is required. This question requires a valid number format.

boxes of surface disinfectant wipes

By what date do you need those boxes of surface disinfectant wipes? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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