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    Aris Setiyobudi
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    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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    Request for Medical Materials Form

    Judul Asli

    Request for Medical Materials Form

    Hak Cipta

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    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.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai XLSX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    48 tayangan3 halaman

    Assistant

    Diunggah oleh

    Aris Setiyobudi
    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.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai XLSX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 3

    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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