Employee Portal

Health Services Supply Request Form

This form is typically utilized by Residential, ALS, Avenue A, and Avenue B. Medical Supplies are fulfilled by the Health Services Team. Please be sure to complete the form in it’s entirety.

Should you have any problems with this form, please contact Tasha Miller.

Name(Required)

First Last

Email(Required)

Location(Required)

Items Requested

Briefs - Tabs (Comes in Packages of 20-50 Based on Size or a Case of 4 Packages)

These briefs include the tabs on the side and are not a pull up brief.

Size

Package or Box

Qty of Package/Box Needed

Briefs - Pull Ups (Comes in Packages of 20-50 Based on Size or a Case of 4 Packages)

These briefs are the pull up briefs and do not have tabs on the side.

Size

Package or Box

Qty of Package/Box Needed

Underpads/Chux (Comes in a Case of 6 packages that have 25 underpads each))

These are used on chairs and beds.

Number of Cases Needed

Gloves (Comes in boxes of 100 OR a Case of 10 boxes of 100)

Size

Box or Case

Qty of Box or Cases Needed

Wipes (Comes in Case of 12 packages with 64 wipes each)

Qty of Cases Needed

Med Cups (Comes in Sleeve of 50)

Number of Sleeves Needed

Narcotic Medication Administration/Count Sheets

Number of Sheets Needed

Peer Review Forms

Number of Forms Needed

Med/Coin Envelopes

Qty Needed

Other Items

Other Items Needed Not Listed Above