Event Supply Request Form
To be completed by a manager
Requester Name
*
First Name
Last Name
Requester Email
*
example@example.com
Shiftboard ID # XXXX-XXXX any updates- write EDIT in front of # (if multiple do, EDIT #1 XXXX-XXXX)
*
Client
*
Event City / State
*
Client ZIP CODE
*
Date of Event
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Projected Participation
*
Event Type
*
Biometrics - Fingerstick
Biometrics - Venipuncture
COVID Testing
FLU Clinic
COVID Vaccine
Other Vaccine
LAB SETUP
AHA Moment
Turner Site Supplies
Supplies needed by
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shipping supplies to:
*
Team Lead / Lead Nurse
Client Site
Hotel
FedEx/UPS
Other
Guest Check-In Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hotel Name
Client Site Name
Shipment Recipient Name
*
First Name
Last Name
Shipment Recipient Phone
-
Area Code
Phone Number
Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Supplies are to be shipped back to KOP
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Shipping Instructions
Fingerstick Bloodwork Supplies
Rows
Quantity Requested
BLUE BAG: Stadiometer with headpiece, Scale and board, Large BP cuff, XL BP cuff, stethoscope, ancillary Tray, gloves, disposable trash can, trash bag, red bag, body fat analyzer, hand sanitizer, extension Cords, surge protector, pack of AAA, tablecloth, tape measure, BMI chart, Cardio Protocol/Log
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CardioChek Analyzer (2+ per fingersticker; all devices come with optics)
PTS Test Strips (TC/HDL/GLU/TRIG/LDL) boxes of 15
PTS Test Strips (TC/HDL/GLU) boxes of 15
CardioChek Liquid Controls- 1 box per 10 clinics (includes high and low controls)
Capillary Tubes - 16 in a bag
Bloodwork plastic tray- 1 per fingersticker- holds 100 lancets, alcohol, bandaid, gauze
Lancets- 1 box of 200
Alcohol Prep Pads- 1 box of 200
Bandages- 1 box of 100
Gauze / Cotton- 1 sleeve of 200
Standard professional towels
EnviroMed
SHARPS
- 1 qt small mailback (25 biometric/20 venipuncture/50 flu)
EnviroMed
SHARPS
- 1 qt red sharps containers
EnviroMed
SHARPS
- 5 qt mail back - holds 4 1 qt red sharps
EnviroMed- 5 qt low top sharps
EnviorMed- 7.5 gallon waste holds 12 1 qt red sharps
EnviroMed - 15 Gal Waste Box
Biohazard Bags (3 min per event)
Hygrometer - measures Temp/Humidity (
Required for testing events)
Gloves - S order by pairs (500 expected=500 pairs)
Gloves- M order by pairs (500 expected=500 pairs)
Gloves - L order by pairs (500 expected= 500 pairs)
Gloves - XL order by pairs (500 expected= 500 pairs)
Bloodwork Lab Coat- small
Bloodwork Lab Coat- M
Bloodwork Lab Coat- L
Bloodwork Lab Coat - XL
Surgical Masks for Staff
Blood Spill Kit
Plastic tablecloths
Hand sanitizer - 1 per staff + 1 at each registration
AA Batteries (CardioChek takes 4)
Privacy Screens (2 for per POD)
Sani-Wipes (medical-grade)
Pens- order by the single pens
Packing tape - order by the roll
Clipboards- paper events only
Disposable trash cans
Trash bags
Power Strip
Extension Cord
Ipads with keyboards and chargers- 1 for each staff + 1 or 2 for registration
CLIA licensure and other state permits
Consent Form HWs- paper - # of expected participation
Participant Result Form- # of expected participation
Onsite Risk Referral Risk Form - BP/Glucose (carbon copy)
Fingerstick collection- standing order- 1 per clinic
----------------------------------------------------
Biometric Compentency Check-off: send 1 per staff
CardioChek Control page
CardioChek steps 1-9
Station Signage- client request only
Name Tags
Manilla folders
Paper clips
CardioChek troubleshooting
Wifi Hotspot
---------------------------------------------
Mailback Envelope for paper Consents with Label
Cots
Hand warmers
Speakers for music
BMI chart
Fingerstick Results Back-up Form
Automatic Blood Pressure cuff for Training
Turner Site Supplies
Rows
Quantity Requested
Vaccine/Immunizations_______________________________________________
Alcohol wipe
Band aid
Epinephrine auto injectors- Pack of 2
General Medical Supplies
AED
Bag valve mask
Biohazard bags
Blankets
Regular BP cuff
Large BP cuff
Stethoscope
Fire extinguisher
Glucose monito
Test strips
Lancets
Heating/cooling blanket
IV stand/pole
Light source Headlamp
Flashlights
Otoscope w/ replacement tips (FB in ears)
Pen light
Pillows
Privacy screens/curtains
Procedure trays
Pulse oximetry device
Saline
Sharps container
Stopwatch
Trash Bags
Trash cans
Trauma shears
Weight scale
PPE Supplies_______________________________________________
Face shield
Gloves (non-latex -Small)
Gloves (non-latax, Medium)
Gloves (non-latex, Large)
Gloves (non-latex, XL)
Gowns
Protective eyewear
Surgical masks
First aid/trauma kit_________________________________________
Alcohol
Aloe vera gel
Antibiotic ointment
Antiseptic wipes
Bandages (assorted sizes)
BetadineBleed stopBurn gel
Butterfly bandages/steristrips/bandaids(assorted sizes)
cotton balls
Duct tape
First aid manual
Gauzes (assorted sizes)
Hand sanitizer
Ice packs/instant cold packs
Medical bag
Medical tape
Non-adherent dressings
Petroleum jelly/lubricant
Plastic bags (assorted sizes)
Safety pins (assorted sizes)
Scissors/forceps
Skin glue/tissue
adhesiveSyringes,
medicine cup/spoon
Thermometer
Tongue depressors
Tourniquet
Towelettes
Medications______________________________________________
Antacids
Anti-diarrheal
Antihistamines
Dextrose (glucose)
Epinephrine (auto-injectors)Pack of 2
Hydrocortisone
Ibuprofen
Laxatives
Tylenol
Eye injuries_______________________________________________
Eye wash station
Morgan's lens w/ tubing
PH strips
Visual acuity chart
Wound cleansing__________________________________________________________
Clinical basinsBowls
Pans
Saline flushes
Splash cap
Sterile saline (0.5Land 1 liter bottles)
Irrigation devices50cc syringes
Splash cap
MSK injuries_______________________________________________________
Cervical spine collar (C-spine)
EMS/spine board
First aid splint
Orthopedic supports/splints
ACE wraps
Aluminum finger splints
Ankle brace
Arm/shoulder brace
Back brace
Wrist brace
Burns_________________________________________________________________
Antibiotic ointment
Burn dressings (Xeroform -petroleum impregnated dressings)
Kerlex
Venipuncture Bloodwork Supplies
Rows
Quantity Requested
BLUE BAG: Stadiometer with headpiece, scale and board, regular BP cuff, large BP cuff, stethoscope, ancillary Tray with no lancets, gloves, disposable trash can, trash bag, red bag, body fat analyzer, hand sanitizer, extension Cords, surge protector, pack of AAA, tablecloth, tape measure, BMI chart
BD Vacutainer SST tubes (Tiger Top) (1 standard for 3 tests; 1 extra for nicotine)
BD Vacutainer Lavender tubes (1 standard; 1 extra for A1C)
BD Vacutainer Holders (must match needle #)
21 gauge straight safety needle 1.25"
23 gauge butterfly safety needle 3/4"
Blood collection tube holder/ rack- 1 per PHLEB
Tourniquet band
Specimen bags
Large baggies- for individual specimen bags- (one bag can fit like 15 specimens)
Fine-tipped sharpies to write of tubes
LABCORP Lab Requisitions- make sure acct # matches correct CLIENT
Plastic tray- with bandaids, alcohol preps, gauze
Alcohol Prep Pads- 200 in a box
Bandages-100 in a box
Gauze- sleeve of 200
Standard Professional Towels
EnviroMed SHARPS - 5 qt high top sharps - can fit 35 needles/vacutainers/tubing
EnviroMed- 7.5 gallon waste (fits 12 1 qt red sharps containers)
EnviroMed- 15 gallon waste
Biohazard Bags
Gloves - S order by the pairs (500 expected=500 pairs)
Gloves- M order by the pairs (500 expected=500 pairs)
Gloves- L order by the pairs (500 expected= 500 pairs)
Gloves- XL order by the pairs (500 expected= 500 pairs)
Bloodwork Lab Coat- Small
Bloodwork Lab Coat- Medium
Bloodwork Lab Coat- L
Bloodwork Lab Coat - XL
Surgical Masks for staff
Blood Spill Kit
Centrifuge
Plastic tablecloths
Hand sanitizer - 1 per staff + 1 at each registration
Privacy Screens (2 screens per POD)
Sani-Wipes (medical-grade)
Pens- order by single pens
Packing tape- order by the roll
Clipboards- paper events only
Disposable trash cans
Trash bags
Power Strip
Extension Cord
Ipads with keyboards and chargers - 1 for each staff + 1 or 2 for registration
WIFI hotspot
Name Tags
Manilla folders
Paper clips
CLIA licensure or other state permits
---------------------------------------------------
Participant Result Review sheet- Venipuncture
Consent form * PAPER EVENTS ONLY
Onsite Risk Referral Forms- BP/Glucose (need 5-10 per clinic)
Biometric Compentency Check-off: send 1 per staff
Mailback Envelope for Paper Consents with Label
Mailback Envelope for Routing Sheets with Label going to Nicole and Stacy-*CHS events
Cots
Hand warmers
Speakers for music
Dolly for hauling boxes- ULINE fold up
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BMI chart
station signage
VENIPUNCTURE Table Top WARNING sign- 1 per blood draw station
Venipuncture Back-up Result Form
Avery Labels for Lab Req and blood draw tubes
Label cards for Avery Lables
COVID Vaccine Clinic Supplies
Rows
Quantity Requested
COVID Vaccine - only order if event is in PA
25 gauge safety needle 1"
25 gauge safety needle 1.5" - 10% of projected
25 gauge safety needle 5/8" (pediatrics)
Administration Syringe - Single use 1mL/cc
Alcohol Prep Pads
Bandages
Cotton Balls
Surgical Masks
Paper pads-
EnviroMed SHARPS - 1 qt small mailback (50 flu)
EnviroMed SHARPS - 1 qt red sharps (50 flu)
EnviroMed SHARPS - 5 qt mailback- round container (150 flu)
EnviroMed- 5 qt mailback- holds 4 1 qt red sharps
EnviroMed- 7.5 gallon waste (fits 12 1 qt red sharps)
EnviroMed - 15 Gal Waste
Biohazard Bags -only in large events
Vericor Cooler with 6 panels including Digital Data Logger (DDL)
Gloves, Nitrile or Vinyl - S order by pairs (500 expected=500 pairs)
Gloves, Nitrile or Vinyl - M order by pairs (500 expected=500 pairs)
Gloves, Nitrile or Vinyl - L order by pairs (500 expected= 500 pairs)
Gloves, Nitrile or Vinyl - XL order by pairs (500 expected= 500 pairs)
Post-op timers with batteries
AAA Batteries (timers take 2)
Epinephrine pack( twin pack of 2) **REQUIRED**
PEDS Epinephrine pack (twin pack of 2) **Required for all PEDS events**
Benadryl/diphenhydramine 25 mg tablets
Benadryl/Diphenhydramine-ped chewable tablets
Ammonia capsules
Manual Blood Pressure Cuff - Adult
Manual Blood Pressure Cuff - Adult Large
Stethoscope
Pulse Ox
Pencil Cases- with pre-drawn labels taped
Dry Erase Markers
Expo Boards
Sharpies
Highlighters
Plastic tablecloths
Hand sanitizer - 1 per staff + 1 at each registration
Privacy Screens
Sani-Wipes (medical-grade)
Pens- order by single pens
Packing tape
Clipboards
Disposable trash cans
Trash bags
Power Strip
Extension Cord
Ipads with keyboards and chargers- 1 for each staff + 1 or 2 for registration
Station Signage- client request only
COVID-19 Paper consent (PAPER ONLY EVENTS)
Health Screening Participant Questionnaires (PAPER EVENTS ONLY)
EUA Fact Sheet QR codes- (all manufacturers)
Prep & admin summary- Pfizer Purple cap- ages 12+
Prep & admin summary- Pfizer grey cap- ages 12+
Prep & admin summary - Pfizer PEDS orange cap- ages 5-11 **need PEDS needles
Prep & admin summary- Moderna (all types)
Prep & admin summary- Novavax- ages 12+
Prep & admin summary- J&J, 18+
Standing Orders- Moderna PEDS (6-11yo) (NV, GA, NY)
Standing Orders- Moderna (12+yo) (NV, GA, NY)
Standing Orders- Moderna Bivalent 18+yo (NV, GA, NY)
Standing Orders- Pfizer PEDS (5-11 ages)
Standing Orders- Pfizer 12+yrs (purple cap-requires reconstitution) (NV, GA, NY)
Standing Orders- Pfizer 12+yrs (grey cap- NO reconstitution)
Standing Orders- Pfizer Bivalent 12+yrs (NV, GA, NY)
Standing Orders- Novavax 12+yrs (NV,GA,NY)
Standing Orders- J&J 18+yrs (NV,GA,NY)
Colorado CIIS notice for CO events only
V-safe Info Sheet- QR code
Sign in sheet
PIL form
Internal Vaccination schedule
Participant dose administered log
Pre-Draw Vaccine Inventory Log
Vaccine Transport Log
Hourly Vaccine Temperature Log
SIRVA poster
Pre-Vaccination Administration Checklist
Anaphylaxis poster
Adverse Reaction Management- Adults Standing Order
Adverse Reaction Management- PEDS Standing Order
Vaccine Adverse Event Reporting (VAERS) and Deviation Policy
EnviroMed Instruction sheet
VIS sheets- English
Privacy Practices- *** (paper events only)
COVID-19 Vaccination Cards (must have authorization from Clinical OPs to order)
Traceable DDL
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WIFI hotspot
Mailback envelope for paper consents with Label
Station signage
Flu Vaccine Clinic Supplies
Rows
Quantity Requested
Flu Vaccine - Flucelvax or Afluria
Flu Vaccine- Fluad 65+
25 gauge safety needle 1"
25 gauge safety needle 1.5" - 10% of projected
25 gauge safety needle 5/8" (pediatrics)
21 gauge Transfer Needles 1.5" (Monkeypox only)
Administration Syringe - Single use 1mL/cc
Alcohol Prep Pads
Bandages
Cotton Balls
Paper pads-
Surgical masks
EnviroMed SHARPS - 1 qt mailback (50 flu)
EnviroMed- 1 qt red sharps container
EnviroMed SHARPS - 5 qt mailback- round container (150 flu)
EnviroMed SHARPS - 5 qt mailback (can hold 4 1 qt. red sharps)
EnviroMed- 7.5 gallon waste (fits 12 1 qt red sharps)
EnviroMed - 15 gallon waste
Biohazard Bags- only large events
Styrofoam Cooler with 3 Temperature Cards
Gloves, Nitrile or Vinyl - S order by pairs (500 expected= 500 pairs)
Gloves, Nitrile or Vinyl - M order by pairs (500 expected= 500 pairs)
Gloves, Nitrile or Vinyl - L order by pairs (500 expected= 500 pairs)
Gloves, Nitrile or Vinyl - XL order by pairs (500 expected= 500 pairs)
Epinephrine pack( twin pack of 2) **REQUIRED**
PEDS Epinephrine pack (twin pack of 2) **Required if a PEDS event
Benadryl/diphenhydramine PEDS chewable
Benadryl/diphenhydramine 25 mg tablets
Manual Blood Pressure Cuff - Adult
Manual Blood Pressure Cuff - Adult Large
Stethoscope
Pulse Ox
Ammonia capsules
Pencil Cases- to put syringes in onsite
Dry Erase Markers
Expo Boards
Sharpies
Plastic tablecloths
Hand sanitizer - 1 per staff + 1 at each registration
Privacy Screens (2 screens per flu nurse)
Sani-Wipes (medical-grade)
Pens- order by single pens
Packing tape
Clipboards- PAPER EVENTS ONLY
Disposable trash cans
Trash bags
Power Strip
Extension Cord
Ipads with keyboards and chargers- 1 for each staff + 1 or 2 for registration
VIS sheets- English
VIS sheets-Spanish
Physician Standing Orders (NY and GA have their own*see below)-1 per clinic
Anaphylaxis and Adverse Reaction Management policy-1 per clinic
Sign in sheet- 1 per clinic
Influenza Administered Dose Log - # of nurses adminstering
Influenza PIL form - 1 per clinic
WC Influenza consent form- (PAPER events only)
Privacy Practices (Paper events only)
Influenza Vaccination Record Cards (client request)
NY Influenza Standing orders (Dr Z and nurses need to sign)
GA Influenza Standing orders (Dr Z and nurses need to sign and get notarize)
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WIFI hotspot
Mailback Envelope for Paper Consents with Label
Additional Vaccine Comments **SPECIFY FLU / VACCINE**
*
Lab Set Up
Rows
Quantity Requested
Vaccine Sign in/out form
Vaccine received inventory log
Cold storage labels
Vaccine fridge
Vaccine freezer
Keys for ABS fridge
PW DDLs
Ice packs
Traceable DDLs
Vericor cooler with all 6 panels
Packing Tape
Pens
5 quart Sharps containers
Bubble Wrap
Clipboards
Additional comments on bloodwork supplies
AHA Moment
Rows
Quantity Requested
Labtops
iPads
Hotspot
Hand sanitizers
Sani-wipes
Mailback Envelope with label to Stacy and Nicole
HIPAA Form
Body Composition
Rows
Quantity Requested
Manual Blood Pressure Cuff - Children
Manual Blood Pressure Cuff- Adult regular
Manual Blood Pressure Cuff- Adult Large
Manual Blood Pressure Cuff - XL (thigh)
Automatic Blood Pressure Cuff
Stethoscope
Tape Measure - 60" (send 1 per pod)
Tape Measure- 120" (send at least one event)
Weight Scale with wood BOARD
Stadiometer with head piece
Body Fat Analyzer (OMRON)
AAA batteries for omron/scales
Body Fat Warning Sign- 1 per Omron
Additional Testing
Rows
Quantity Requested
A1C Now+ (10 in a box)- must order a complete box
A1C Now+ controls
Blood Card A1C/PSA/TSH (double ancillaries per additional test)
Cotinine - Alere iScreen (25 in a box)
COVID Testing Supplies
Rows
Quantity Requested
Antigen test kits ( FlowFlex)
# of controls, if need extra ****MUST order BINAX controls for FLOWFLEX
Confirmatory test kits (Lucira, Accula, CUE)
# of devices/docks
# of controls, if need extra
Status- COVID/Flu test kits
Baskets + Timers
COVID PPE Gown (all staff) - One Size
COVID PPE Gown - XL
N95 Masks (all staff)
Surgical Masks (participants only, per client request)
COVID PPE Face Shield (all swabbers)
Biohazard Red Bags (4 min per event)
EnviroMed SHARPS - 1 qt mailback
EnviroMed SHARPS - 1 qt red sharps containers
Enviromed- 5 qt mailback- holds 4 1 qt red sharps containers
Enviromed- 7.5 gallon waste
Enviromed- 15 gallon waste
Gloves, Nitrile or Vinyl - S order by pairs (500 expected=500 pairs)
Gloves, Nitrile or Vinyl - M order by pairs (500 expected=500 pairs)
Gloves, Nitrile or Vinyl - L order by pairs (500 expected=500 pairs)
Gloves, Nitrile or Vinyl - XL order by pairs (500 expected=500 pairs)
CLIA licensure and other state permits
Tissues
Hygrometer - measures Temp/Humidity (
Required for testing events)
Plastic tablecloths
Hand sanitizer - 1 per staff + 1 at each registration
AAA Batteries (timers take 2)
Privacy Screens (if required)
Sani-Wipes (medical-grade)
Pens (1 pen cup included)- order by single pens
Packing tape- order by roll
Clipboards
Disposable trash cans
Trash bags
Power Strip
Extension Cord
Ipads with keyboard and charger- 1 for each staff + 1 or 2 for registration
Name Tags
Manilla folders
Paper clips
WIFI hotspot
Participant Result Cards
Specimen Tracking Log- *PCR lab processed specimens
Staff Sign In Sheet
Medical Waste Collection and Return Kit Assembly Instructions
Rymedi Stickers
COVID PIL Form
Credit Card Readers
Mailback envelope for Paper Consents with Label
station signage
CLIA licensure and other permits
Please provide any additional comments (regarding paperwork and/or supplies)
Upload any files for printing - Consents, handouts, etc.
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Date Request Received
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Request Received By
First Name
Last Name
Date "To Be" Shipped- Dry supplies
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tracking Information for dry supplies
Full #, separated on each line
Date "To Be" Shipped- vaccines
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tracking Information for vaccines
Full #, separated on each line
Shipment received
YES
NO
Save
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Event Necessities
Rows
Quantity Requested
Plastic tablecloths
Hand sanitizer - 1 per staff + 1 at each registration
AA Batteries (CardioChek takes 4)
AAA Batteries (omron/timers take 2)
Privacy Screens (3+ for each bio /2 screens per flu nurse)
Sani-Wipes (medical-grade)
Pens (1 pen cup included)
Packing tape
Clipboards
Disposable trash cans
Trash bags (4 min per event)
Power Strip
Extension Cord
Ipads- 1 for each staff + 1 or 2 for registration
High Risk Referral Forms (carbon copy) BIO ONLY
Station Signage- client request only
Educational Handouts- Bio only
Name Tags
Paperwork Tray (2 per event w/paper)- Bio only
Manilla folders
Paper clips
Should be Empty: