SEIU 503 PPE Request Form

Please fill out the form below if you need medical grade PPE. As supplies become available through DHS, our Union will provide your information to the Agency and push them to prioritize members who need PPE the most.

Translation assistance

Spanish: Para asistencia en Español, por favor comuníquese con el Centro de Asistencia al Miembro al teléfono 1-844-503-SEIU (7348).

Vietnamese: Để được hỗ trợ bằng tiếng Việt xin vui lòng gọi Trung tâm hỗ trợ thành viên tại 1-844-503-SEIU (7348).

Arabic: 1-844-503-7348 للمساعدة باللغة العربية يرجى الاتصال بمركز مساعدة الأعضاء على

Korean: 한국어로 도움이 필요하시면 회원 지원 센터 1-844-503- SEIU (7348)로 문의하십시오.

Traditional Chinese*: 如需中文服務請撥打SEIU會員服務中心，電話 1-844-503-7348。Simplified Chinese*: 如需中文服务请拨打SEIU会员服务中心，电话 1-844-503-7348。

First Name

Last Name

Middle Initial

Not you? If this form is prefilled with the wrong information, click here.

Cell phone †

†By providing my phone number, I understand that the Service Employees International Union (SEIU), its local unions, and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Reply STOP to stop receiving messages; reply HELP for more information.

Mailing Street

Mailing City

Mailing State

Mailing Zip

Provider type (HCW/PSW/PCA/Multiple)

Provider Number

Help DHS prioritize its PPE.

Let us know what you and your clients need, so we can push DHS to prioritize SEIU members.

Type of PPE requested (masks or gloves)

Glove Size

Number of Consumers

Average Hours Per Consumer Per Pay Period

Local Office

City Office is Located in

DHS Pick-Up Preference

Individuals who fall under the following categories are not eligible to receive PPE through this request process:

You are an active homecare or personal support worker, but you have not provided services for an eligible individual during the past three months.

You live outside of Oregon and you are not supporting an individual in Oregon and you are not enrolled as a homecare or personal support worker in Oregon.

You are another type of provider that is not supported through this distribution process.

Please confirm that you have read this disclaimer and the eligibility requirements for medical grade PPE. Thank you.

Contact Information