MasksOn.org Request Form 5-21-2020

MasksOn.org Request Form

MasksOn.org Reusable Face Shield is a Face Shield for Medical Purposes - authorized by the FDA's Emergency Use Authorization (EUA) for face shields. Please check MasksOn.org for instructions, important warnings, and frequent updates.
Due to greatly increased demand and nearly exhausted inventory / funds, your request will be added to a waitlist. We can no longer guarantee that you will receive a face shield or when it will be delivered.

If you are able, a donation will extend our ability to donate face shields to clinicians: https://maskson.org/donate
- This device is only for use when FDA-cleared masks or respirators are unavailable
- This device is intended for multiple uses by the same user
- This device requires an airway filter certified for "Bacterial/Viral" filtration (not included)
- This device cannot be used while wearing eyeglasses
- Read all clinician information and warnings at https://MasksOn.org before proceeding
By proceeding, I agree to these terms and conditions: MasksOn.org Face Shields are for use only when FDA-cleared masks or respirators are unavailable and while the FDA's Emergency Use Authorization (EUA) for face shields is in effect. I understand that these face shields do not come with a "Bacterial/Viral" filter and I will need to provide one. I have viewed the MasksOn.org site for instructions and important warnings. I intend to use these face shields in an institutional healthcare setting. *

Yes No

Healthcare Institution Name: *
Healthcare Institution Address: *

Street Address

Street Address Line 2

City State

Zip Code
Delivery Address (If Different from Healthcare Institution):

Street Address

Street Address Line 2

City State

Zip Code
Delivery address is: *

Business Address Residential Address
Optional delivery notes:
Your Contact Information: *

First Name Last Name
Your Role with Healthcare Institution: (i.e. Title) *
Your Cell Phone Number to Facilitate Delivery: *

Area Code Phone Number
Your Email Address: *
example@example.com
Healthcare Administrator's (PPE decision maker's) Name: *

First Name Last Name
Healthcare Administrator's (PPE decision maker's) Email Address (required for FDA notices): *
example@example.com
Alternate Contact's Best Phone Number:

Area Code Phone Number
Your Affiliation with Healthcare Institution: *
If Affiliation is Other Please explain:

REQUESTS RECEIVED WITHOUT VALID SIGNATURE ON "LETTER OF UNDERSTANDING AND INDEMNIFICATION" WILL NOT BE FILLED.

questions@maskson.org
Date

Month Day Year
Date Hour Minutes
Letter of Understanding & Indemnification

In response to, and in consideration of, the COVID-19 emergency, by signing this Letter of Understanding below, you, on behalf of and in connection with your role at: {healthcareInstitution} a healthcare facility or healthcare provider (“Provider”), understand and agree to the following terms and conditions with respect to the order of Masks On Corporation and any instructions related to the use thereof (the “Component Parts”) made by Provider on {date} and supplied to Provider by Masks On Corporation, a Massachusetts not for profit corporation to be formed, or any of its volunteers, contributors, partners, agents, or representatives (collectively “Masks On”) (see MasksOn.org):

1.     Provider understands that all Component Parts provided by Masks On are either (i) generic components, (ii) parts manufactured pursuant to specifications provided by Provider to Masks On, or (iii) requested as-is at the instruction of the Provider. Both Parties agree that such Component Parts provided by Masks On are not and do not constitute finished medical products.

2.     Provider shall solely determine how such Component Parts are used and shall use such Component Parts at Provider’s sole discretion.

3.     Provider understands that Masks On is currently not a registered/licensed medical device manufacturer with the U.S. Food and Drug Administration (“FDA”) or any applicable ANY regulatory agency.

4.     Provider understands and agrees that Masks On has not conducted performance testing, functionality testing or validation testing with respect to the Component Parts or use of Component Part for any purpose, including biocompatibility testing that may be relied upon by Provider. Any such testing, if required, shall be the sole responsibility of Provider.

5.     Provider understands and agrees to indemnify and defend Masks On for all costs and liability, including attorney fees and all regulatory compliance and liability, related to the supply and use of Component Parts provided by Masks On, any Provider specifications for the Component Parts, distribution of the Component Parts or other products that incorporate the Component Parts by Provider.

6.     Provider understands and agrees that the Component Parts are provided on an “as is” and “as available” basis, and without any representation, warranty, guarantee or condition of any kind whatsoever, whether express, implied or statutory, including without limitation any implied warranties of merchantability, fitness for a particular purpose, satisfactory quality, quiet possession, title, quality of service, non-infringement, or that otherwise arise from a course of performance or dealing, or usage of trade, all of which are hereby disclaimed by Masks On.

7.     The undersigned agrees and acknowledges that he/she/they are signing on behalf of Provider and in relation to any use of the Component Parts by Provider or any representatives of Provider, and that Masks On may rely on the undersigned’s authority to bind Provider regarding the use of such Component Parts.

ACCEPTED AND AGREED as of {date}

{healthcareInstitution}, {yourContact}, {yourEmail}

NAME OF PROVIDER

{typeA}

SIGNATURE

{yourRole}

TITLE
AFTER YOU FINISH SIGNING IN DOCUSIGN PLEASE BE SURE TO CLICK THE BLUE "CLOSE WINDOW" BUTTON IN THE MIDDLE OF THE SCREEN TO ENSURE YOUR REQUEST IS RECEIVED.

REQUESTS ARE PROCESSED IN THE ORDER THEY ARE RECEIVED BY A VOLUNTEER TEAM. YOU DO NOT NEED TO REACH OUT TO FIND OUT IF YOUR REQUEST HAS BEEN RECEIVED - WITH VALID EMAIL YOU WILL RECEIVE A COPY.

YOU WILL HEAR FROM US WHEN YOUR REQUEST IS PROCESSED OR IF WE NEED MORE INFO.
Letter of Understanding & Indemnification

In response to, and in consideration of, the COVID-19 emergency, by signing this Letter of Understanding below, you, on behalf of and in connection with your role at: {healthcareInstitution} a healthcare facility or healthcare provider (“Provider”), understand and agree to the following terms and conditions with respect to the order of Masks On Corporation and any instructions related to the use thereof (the “Component Parts”) made by Provider on {date} and supplied to Provider by Masks On Corporation, a Massachusetts not for profit corporation to be formed, or any of its volunteers, contributors, partners, agents, or representatives (collectively “Masks On”) (see MasksOn.org):

1.     Provider understands that all Component Parts provided by Masks On are either (i) generic components, (ii) parts manufactured pursuant to specifications provided by Provider to Masks On, or (iii) requested as-is at the instruction of the Provider. Both Parties agree that such Component Parts provided by Masks On are not and do not constitute finished medical products.

2.     Provider shall solely determine how such Component Parts are used and shall use such Component Parts at Provider’s sole discretion.

3.     Provider understands that Masks On is currently not a registered/licensed medical device manufacturer with the U.S. Food and Drug Administration (“FDA”) or any applicable ANY regulatory agency.

4.     Provider understands and agrees that Masks On has not conducted performance testing, functionality testing or validation testing with respect to the Component Parts or use of Component Part for any purpose, including biocompatibility testing that may be relied upon by Provider. Any such testing, if required, shall be the sole responsibility of Provider.

5.     Provider understands and agrees to indemnify and defend Masks On for all costs and liability, including attorney fees and all regulatory compliance and liability, related to the supply and use of Component Parts provided by Masks On, any Provider specifications for the Component Parts, distribution of the Component Parts or other products that incorporate the Component Parts by Provider.

6.     Provider understands and agrees that the Component Parts are provided on an “as is” and “as available” basis, and without any representation, warranty, guarantee or condition of any kind whatsoever, whether express, implied or statutory, including without limitation any implied warranties of merchantability, fitness for a particular purpose, satisfactory quality, quiet possession, title, quality of service, non-infringement, or that otherwise arise from a course of performance or dealing, or usage of trade, all of which are hereby disclaimed by Masks On.

7.     The undersigned agrees and acknowledges that he/she/they are signing on behalf of Provider and in relation to any use of the Component Parts by Provider or any representatives of Provider, and that Masks On may rely on the undersigned’s authority to bind Provider regarding the use of such Component Parts.

ACCEPTED AND AGREED as of {date}

{yourContact}, {yourEmail}

NAME OF PROVIDER

{typeA}

SIGNATURE

{yourRole}
Bacterial / viral airway filters are required and are NOT supplied by MasksOn. We cannot process your order if you do not have access to these filters (see https://maskson.org/info). Do you have access to the required "bacterial/viral" filters? *

Yes No
Will your healthcare institution provide the required “Bacterial/Viral” airway filters? *

Yes No
GEOSTAMP DATA COLLECTOR
I agree to the terms above. *

Yes No
I have filled this form correctly and accept all terms in the Letter of Understanding and Indemnification included. Signed: *

Sign Here - Then click 'Submit' button below to submit your form request. Clear
Due to greatly increased demand and nearly exhausted inventory / funds, your request will be added to a waitlist. We can no longer guarantee that you will receive a face shield or when it will be delivered.

If you are able, a donation will extend our ability to donate face shields to clinicians. Please see https://maskson.org/donate

FORM ENTRY DOES NOT MEET MASKSON.ORG REQUIREMENTS.

Please visit MasksOn.org for more information or email questions@maskson.org
Should be Empty:

MasksOn.org Request Form

Mask Selection