Organization Production Address:
* - Select - Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Your First Name
Your Last Name
Your Phone Number
Who should be the contact for your organization, if different from yourself?
What is the email address for the contact for your organization, if different from yourself?
What is the phone number for the contact for your organization, if different from yourself?
You or your identified Contact's Position within your organization
Section a: Request Reasonableness
Answers to the following questions will allow for the M-ERT to assess if the applicant is requesting a reasonable amount of funding related to the production increase promised in the application.
Request for Funds
Please describe your request and why this funding is needed at this time.
Description of Matching Funds:
What will the funds be used for? (Check all that apply)
If requesting funding for equipment, materials or supplies, please provide details on your confidence and timeline for sourcing equipment, supplies and materials.
If requesting funding for workforce training, for the purpose of PPE production, do you expect to use the funding to do any of the following employment changes:
retrain existing workers,
onboard and train new hires, or
train temporary workers for the purpose of PPE production?
Please note: training may include both formal training from external experts and informal training by other employees (e.g. on the job training or shadowing).
Please provide an answer:
Section b: Legitimacy of the Request
Answers to the following questions will allow for the M-ERT to assess if the ability of the applicant to produce promised materials. This will include a review of the production capacity form.
Please describe the applicant’s history and experience in manufacturing goods, specific history around making PPE materials should be noted.
* Have you filled out the Capacity Index Form?
If No, please fill out the form here.
Section c: Production of Priority Item
Answers to the following question will allow for the M-ERT to assess if the applicant making invasive or multifunctional ventilators (FDA certified), N95 Respirators, or Surgical Masks will be given preference. (Others items may be considered priority as we get guidance from the demand group of the M-ERT)
What will these funds allow you to produce?
Section d: Production Amount
Answers to the following questions will allow for the M-ERT to assess if the applicant will produce an increased amount of PPE, the larger quantities will be given preference.
Please note quantity of any item checked above.
Please provide any additional detail about the production of these items, including total quantity of each item.
Please describe the path forward for getting FDA or other approval for this item
Section e: Production Timeline
Answers to the following questions will allow for the M-ERT to assess if the applicant will produce an increased amount of PPE rapidly, the shorter timelines to production will be given preference.
How many additional items will you be able to produce in the following time periods?
Please provide any additional detail about the timeline for production.
Section f: Other Please provide additional details as necessary to clarify your submission