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First Aid Supply Order Form
First Aid Supply Order Form
Stacey Lambarena

First Aid Supply Order Form

First aid orders must be submitted before the 15th each month. All orders will be compiled and sent to HART on the 15th, with delivery and distribution expected within 5-7 days.

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Free First Aid Supply Order Form Checklist

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First Aid Supply Order

  • First aid supply order for (specify site)

  • Request date

  • Ordered by

First Aid Order

  • Verify that your location has the required quantities of each item listed in parentheses below. If any items are below the American National Standards Institute (Ansi B) required amount, note the quantity needed for ordering. If none needed, leave blank.

  • Sheer Strip 1"x3" Bandage, 100/box item# 1011 (ANSI B required qty - 1)

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  • Tri-Cut Tape item# 1211 (ANSI B required qty - 2)

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  • Cold Pack item# 0515 (ANSI B required qty - 2)

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  • First Aid Spray 2 oz item# 2717 (ANSI B required qty - 1)

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  • Gauze Pads 3"x3" Sterile, 10/box item# 1833 (ANSI B required qty - 1)

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  • ABD Combine Pad Sterile 5"x9" item# 2306 (ANSI B required qty - 4)

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  • Sof-Adhere Sterile 2" Gauze Roll item#1745 (ANSI B required qty - 2)

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  • Tribiotic Ointment, 25/box item# 5484 (ANSI B required qty - 1)

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  • Hand Sanitizer, 25/box item# 5399 (ANSI B required qty - 1)

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  • Sooth A Burn 3.5gm, 6/pk item# 5344 (ANSI B required qty - 5)

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  • Sooth A Burn 4"x4" item# 2910 (ANSI B required qty - 2)

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  • Gloves Nitrile Large, 2 pair item# 0586 (ANSI B required qty - 4)

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  • Eye Clean 4 oz item# 4730 (ANSI B required qty - 1)

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  • Triangular Bandage item# 0261 (ANSI B required qty - 2)

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  • Eye Pads w/tape, 4/unit item# 0270 (ANSI B required qty - 2)

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  • Scissors item# 7342 (ANSI B required qty - 1)

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  • Rescue Blanket #0581 (ANSI B required qty - 1)

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    • 10

  • Microshield Plus CPR Barrier item#2964 (ANSI B required qty - 1)

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  • Windlass Tourniquet item# 2993 (ANSI B required qty - 1)

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  • First Aid Guide item# 0594 (ANSI B required qty - 1)

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  • The below items are optional and are not required by ANSI. Some items may require additional approvals.

  • Sooth A Sting Swabs, 10/unit item# 0440

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  • Biohazard Bag, with Hand Wipes, 2/unit item# 0583

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  • Junior Strip Bandage, 50/box item# 1004

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    • 10

  • Tufflex Fabric Finger Wrap Bandage, 25/box item# 1024

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  • Aquaflex Waterproof Strip 1"x3" Bandage,50/box item# 1046

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    • 10

  • Tufflex Fabric Strip 1"x3" Bandage, 50/box item# 1076

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  • Tufflex Fabric Fingertip Bandage, 40/box item# 1077

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  • Tufflex Fabric Large Fingertip Bandage, 25/box item# 1078

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  • Tufflex Fabric Knuckle Bandage, 40/box item# 1079

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  • Butterfly Closures, 20/box item# 1080

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  • Padded Splint item# 1356

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  • Cohere-Wrap 2" item# 1561

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  • Sof-Adhere Sterile 3" Gauze Roll item# 1746

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    • 10

  • Sof-Adhere Sterile 4" Gauze Roll item# 1747

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    • 8
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    • 10

  • Gauze Pads 2"x2" Sterile, 10/box item# 1832

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  • Gauze Pads 4"x4" Sterile, 10/box item# 1834

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  • Non-Adherent Pads 2"x3", 25/box item# 2131

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  • Bloodblocker Trauma Dressing item# 2302

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  • Wound seal Powder, 2/pk item# 2350

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  • Alcohol Wipes, 50/box item# 2606

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  • Burn Spray 2 oz item# 2729

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  • Hydrogen Peroxide Spray 2 oz item# 2748

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  • Large Cold Pack item# 2936

    • 1
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    • 10

  • Eye Clean 1 oz item# 4726

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  • Biofreeze Pain Gel, 6/bag item# 5338

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    • 10

  • Hydrocortisone Cream, 25/box item# 5396

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    • 10

  • Wound Wipes, 20/box item# 6197

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  • Disposable Tweezer item# 7309

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  • Splinter Aid, 10/pk item# 7319

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  • Eye Cups, 6/vial item# 7744

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  • Aspirin, 100/box item# 5521

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Backprin Back Pain Relief, 80/box item# 5531

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Electrotab Electrolyte, 100/box item# 5551

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Cetafen Extra Acetaminophen, 100/box item# 5576

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Cetafen Cough & Cold Tablet, 100/box item# 5581

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Exaprin, X-S Pain Relief, 100/box item# 5631

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Nutralox Mint Anatacid, 100/box item# 5671

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Proprinal Softgel Ibuprofen, 80/box item# 5696

    • 1
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    • 5
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    • 7
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    • 10

  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Relief-PE Cold Tablet, 100/box item# 5721

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    • 10

  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Full Vehicle First Aid Kit

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  • This item requires approval. Please note the name of the department Director or Senior Leader approval was granted by.

  • Please note the reason a full kit is needed.

  • Note vehicle ID, license plate number, or VIN number this is for.

  • Please explain

  • First Aid orders will be filled once per month for HFHSKKC. Is there anything in your order that is urgent that would need to be ordered immediately?

  • Which item(s)

  • Is there any other items you would like to request that weren't listed?

  • Please describe what you need.

  • To finalize your first aid order, check this box, then click complete to submit.

First Aid Supply Order Form
Stacey Lambarena

First Aid Supply Order Form

First aid orders must be submitted before the 15th each month. All orders will be compiled and sent to HART on the 15th, with delivery and distribution expected within 5-7 days.

Use this Template
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.

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