Early Intervention Face Mask Request Form

Early Intervention Face Mask Request Form

The Bureau of Early Intervention is providing a limited number of standard-sized KN95 face masks to all EI providers of early intervention services. These 3M masks are reusable but not washable.

 

EI payees who have signed an Early Intervention Payee Agreement must fill out the form below to request face masks for those working under their payee agreement.

 

After we have confirmed the payee is active in early intervention and the number of employees on staff, we will send masks to the shipping address provided.

 

The number of masks shipped will depend on availability and the overall number of requests.

 

All requests must be made by April 16.

The Bureau of Early Intervention is providing a limited number of standard-sized KN95 face masks to all EI providers of early intervention services. These 3M masks are reusable but not washable.

 

EI payees who have signed an Early Intervention Payee Agreement must fill out the form below to request face masks for those working under their payee agreement.

 

After we have confirmed the payee is active in early intervention and the number of employees on staff, we will send masks to the shipping address provided.

 

The number of masks shipped will depend on availability and the overall number of requests.

 

All requests must be made by April 16.

 

 

 

answer must be a zipcode like 61864 or 61864-8180

 

 

answer must be an email address

 

Note: Your email will be added to the EIC newsletter mailing list.

answer must be phone number with area code like 217-333-1000

Note: Your email will be added to the EIC newsletter mailing list.

 

answer must be numeric