Please complete the form fields below. Date Please input in MM/DD/YEAR format. Required. Requester Required. Phone Number Required. Email Address Required. Fax Number (optional) Pager Number Required. If you do not have a pager number available, enter "N/A". Clinical Contact For Questions Name Required. Phone Number Pager Number Email Address Fax Number (optional) Product Information: Please forward manufacturer's specifications, literature, pricing and vendor's business card All reusable items require instructions for use that contain detailed cleaning instructions I understand By clicking "I understand" below, you acknowledge that you have read and understand the above statement. Required. Product Name Product Description Please include unit of measure. Required. Manufacturer Required. Mfr. Catalog # Is this an emergent order? Yes No Required. If "Yes", please explain why. If "no", enter "N/A" Required. Is this item used for home care use? Yes No Will this item be used for patient care? Yes No Required. Is this item disposable (for single patient use)? Yes No Required. Comments Questions Does/could this product replace a similar product currently in use? Yes No Required. If so, please describe Describe how the item will improve clinical care/outcomes, if purchased Required. What is the approximate annual *each* usage? Required. Is the item a patient/staff safety improvement? Yes No Required. If so, please describe Will item affect other departments and/or affiliates? Yes No Required. If so, please list them If item will affect other departments, have you communicated product information to them? Yes No Required. If yes, please upload that information Upload One file only.64 MB limit.Allowed types: doc, docx, gif, jpeg, jpg, pdf, png, ppt, pptx, rtf, txt, xls, xlsx. Will the item require approval from another committee or department? Yes No If yes, please list them Will new or additional devices be needed to use this product? (ex., disposables, reusables) Yes No If so, please list the additional equipment or devices Is an evaluation of the item necessary Yes No Required. If yes, please list any locations that may participate Has an evaluation tool, including outcomes and evaluation measures, been developed? Yes No If yes, please provide a contact name with phone number, pager, or email address Will this item require a change in policy, procedures, or protocol? Yes No If yes, please list the policy, procedure, or protocol affected Would the item require education for clinical staff? Yes No Required. If yes, who will carry out this requirement? Will this item have an affect on environmental resources? (ex., cleaning, disposal, or storage) Yes No If yes, please list the resources affected Is this item FDA approved? Yes No Required. Comments regarding FDA approval Do you have any interest in the selection of this item that may been deemed a conflict of interest? Yes No Required. If yes, please describe the relationship you have with the vendor Is there a cost-containment potential with the purchase of this item? Yes No If yes, please describe Is an MSDS required? Yes No Are there any additional brochures, documents or files that would assist in this request? Please attach it below Upload One file only.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml. Submit Leave this field blank
