HTML Preview Doctors Medical Receipt page number 1.
MEDICAL SUPPLY
RECEIPT AND INVENTORY FORM
INCIDENT NAME: INCIDENT #:
A. Supplies/Equipment received from: DATE: / /
Agency:
Unit ID#:
Name:
(Whenever possible, use masking tape and markers to identify all equipment)
B. Supplies/Equipment Received by:
NAME:
INCIDENT POSITION:
No. Item Description (Print All Entries) Unit* Amount
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*Unit - list a measurable description of the item (gauge, gm, ml, bag, doz., etc.)
Form distribution: (Use carbon paper) Original - Medical Supply Coordinator
Copy - Source of Supply
INCIDENT RE-IMBURSEMENT OF ANY SUPPLIES/EQUIPMENT WILL BE BASED
ONLY UPON ORIGINAL FORM LISTINGS.
I-MC-312 (1/8/92)