Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Lutheran Health Network

Inventory Supply Request

This form is to be used to reserve or assign inventory for all CHS hospitals.
Please fill appropriate fields.
              Item(s) Please indicate quantity
  APRON HEAVYWEIGHT BLUE EA
  APRON PULLOVER 28X46 WHITE EA
  BARREL 55GAL EA
  CLOTH SANI X-LARGE 8IN X 14IN PLUS EA
  CUFF POCKET ANEROID ADULT COMPLETE EA
  CUFF POCKET ANEROID ADULT COMPLETE WITH STETHOSCOPE EA
  CUFF POCKET ANEROID CHILD COMPLETE EA
  CUFF POCKET ANEROID CHILD COMPLETE WITH STETHOSCOPE EA
  DISPOSABLE LINEN KITS EA
  DISPOSABLE STETHOSCOPE DUAL HEAD EA
  GLOVE ESTEEM NITRILE 12IN CUFF LG BX/50
  GLOVE ESTEEM NITRILE 12IN CUFF MD BX/50
  GLOVE ESTEEM NITRILE 12IN CUFF SM BX/50
  GLOVE ESTEEM NITRILE 12IN CUFF XL BX/50
  GOWN WHITE MICROPOROUS LG KNIT CUFF EA
  GOWN WHITE MICROPOROUS XL KNIT CUFF EA
  HOOD SURGICAL BLUE BX/100
  HOOD SURGICAL/OVERHOOD WHITE 44 EA6
  LEG COVER SHOE COMBO BX/50
  MASK SURG ANTIFOG W/ FACESHIELD BX/25
  N95 MASK ADULT CHS CA/240
  OVERBOOT COVER DISPOSABLE 450 EA
  QUIK-CARE HAND SANITIZING FOAM 15OZ EA
  Is this request urgent? Needed now     Needed within 24 hours     Needed within 72 hours     No rush    
  When do you need item?
* Which facility is making request?
* Please provide your email address.
You will be notified by email.
  Please describe how inventory item(s) will be utilized.