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Request For Medical Materials Form

This material request form is for Project QMS PRIDE and requests various medical supplies and equipment for their site/department by April 2018. It includes a request for 1 bag mask valve with CO2 detection, 1 backboard with straps, 1 examination light, 5 oxygen masks, urinary catheters, cervical collars, gloves, bandages, splints, medicines like ammonia, lidocaine, and ventolin, and other emergency medical supplies.

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Aris Setiyobudi
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256 views

Request For Medical Materials Form

This material request form is for Project QMS PRIDE and requests various medical supplies and equipment for their site/department by April 2018. It includes a request for 1 bag mask valve with CO2 detection, 1 backboard with straps, 1 examination light, 5 oxygen masks, urinary catheters, cervical collars, gloves, bandages, splints, medicines like ammonia, lidocaine, and ventolin, and other emergency medical supplies.

Uploaded by

Aris Setiyobudi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Material Request Form

Project : QMS PRIDE Requisition No. :

Location : Date : APRIL 2018


Site/Dept reqn No : Required Date :
Medicines/Medical/Office Supplies

SI. A/C
Material Description Qty Unit Remarks
No. Code

Bag Mask valve with built in CO2 detection


1 1 set
device(e.g.AMBU) adult, disposable

2 Backboard, Spinal board,long with straps 1 piece


3 Dressing cart,stainless steel 1 piece
4 Examination Light,wall mounted 1 piece
5 Oxygen cart 1 piece
Oxygen regulator/gauge with flow meter and
6 1 piece
humidifier
7 Pulse oximeter 1 piece
8 CPR board 1 piece
9 Head immobilizer 1 piece
10 Nebulizer 1 piece
11 Emergency bag 1 piece
Books
5 Pharmacology (Drug Handbook) 1 piece
Supplies
1 Applicator cotton, sterile, 6 inch 3 box
2 Band aids 5 box
3 Bandage, Stockinet Bandage size: 2 inch 2 box
4 Ace bandage 3inch 5 piece
5 Ace bandage 4inch 5 piece
6 Ace bandage 6inch 5 piece
7 Kidney Basin 5 piece
8 Battery 1.5 volts (AA) 4 piece
9 Battery 1.5 volts (AAA) 4 piece
10 Betadine swabs and/or solution sticks 3 piece
11 Burn dressing: Sterile burn sheet 60x90 cm 5 piece
12 Catheter: Urathral catherter 14 french 2 piece
Cervical collars sizes:
13 Small adult 3 piece
14 Regular adult 3 piece
15 Cold and Cold packs reusable 5 piece
16 Cotton balls non sterile 10 pack
17 Dressing release, non-adhearing dressing 1 box
18 Emergency blanket, aluminum polymer, fire 5 piece
retarded, heat retainer
Gauze: Sponge gauze, non-sterile, sizes:
19 4x4 3 pack
20 Gauze: Sponge gauze, sterile, sizes:
21 4x4 5 pack
Gloves: exam gloves, sterile, latex, sizes
22 Size 7 1/2 15 pair
23 Size 8 15 pair
24 Nebulizer set 5 piece
25 Oxygen mask adult, simple 5 piece
26 Oxygen mask, non-breathing, adult 5 piece
27 Oxygen nasal cannula, adult 5 piece
28 Paper roll, vanco 4 roll
29 Pocket mask for CPR 5 piece
30 Sharp box with wall brackets, small 2 piece
31 Spandages, elastic bangage, sizes: 1 to 7 1 each box
Splint: cardboard / sam splint
32 Leg splint 24 inch 3 piece
33 Leg splint 18 inch 3 piece
34 Arm splint 18 inch 3 piece
35 Arm splnt 12 inch 3 piece
36 Small plastic pouch, ziplock 2 pack
37 Yellow plastic garbage 3 pack
38 Small sharpcontainer for emergency bag 1 piece
39 Shoe cover 5 pack
40 Hand sanitizer refill (1000ml) 10 bottle
Medicine
1 Ammonia 0.3ml crushable ampule 5 piece
2 Lidocaine 2 % 20ml/vial 2 bottle
3 Lidocaine 2 % Gel 20g/tube 3 tube
4 Citirizine Hcl 10mg 5 box
5 Diphenhyramine 50mg ampule 5 ampule
6 Metoclopramide Tablet 10mg (Anti emetic) 5 box
7 Metoclopramide Injecton 5mg 5 ampule
8 Glucose Powder 5 bottle
9 Sodium Clhoride 10 or 20ml amp 10 piece
10 Sterile Water for Injection 10ml amp 10 piece
11 Relaxon 10 box
12 Isorbide Dinitrate 10mg/tab sublingual tablet 3 bottle
13 Centrum 10 box
14 Moov Cream 5 tube
15 Otrivin 5 spray
16 Strepsils 5 box
17 Clarinase Non-drowse 5 box
18 Ventolin 2.5ml nebule 2 box
19 Voltarin Injection 3 box

Material Requested By: Noted and approved by:


Name: Marion Cortezano Name:

Signature: Signature:

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