Medical Uniform Sign-Out Form
Track issued and returned uniforms for healthcare staff. Please complete all fields accurately.
Staff Member Full Name
*
First Name
Last Name
Internal Staff ID
*
Department/Unit
*
Please Select
Emergency
ICU
Surgery
Pediatrics
Maternity
Laboratory
Other
Role
*
Please Select
Nurse
Doctor
Technician
Support Staff
Other
Uniform Item Category
*
Please Select
Scrubs
Lab Coat
Jacket
Gown
Other
Item Size
*
Please Select
XS
S
M
L
XL
XXL
Other
Quantity Signed Out
*
Item Condition at Checkout
*
Please Select
New
Good
Fair
Other
Sign-Out Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Return Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes (Special Requests or Issues)
Submit
Should be Empty: