Free 53546.pdf - Indiana


File Size: 567.5 kB
Pages: 2
Date: October 21, 2008
File Format: PDF
State: Indiana
Category: Government
Author: wendy clingaman
Word Count: 618 Words, 4,029 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/53546.pdf

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PROVIDER REQUEST FOR SUPPLIES
State Form 53546 (R / 9-08)

Reset Form

INDIANA STATE DEPARTMENT OF HEALTH

INSTRUCTIONS:

1. All Provider information must be complete and accurate, including the Provider number. 2. Indicate amount needed only for supplies you are requesting. 3. Quantities requested cannot be more than the maximum allowance where indicated. 4. Completed forms should be faxed, e-mailed, or mailed to the following: Indiana State Department of Health Lead and Healthy Homes Program 2 North Meridian Street, 5J Indianapolis, Indiana 46204 Fax: 317.233.1630 E-mail: [email protected]

Provider Number: Name of Agency:

PROVIDER INFORMATION Date: (mm/dd/yyyy) Contact Name: City: Agency Phone Number: (Including Area Code)

Street Address: (UPS will NOT deliver to PO Box) State: Email Address: ZIP Code:

SCREENING SUPPLIES (Non-Medicaid Only) Adhesive Bandages (100 per pack) Alcohol Preps (Box of 100) Gauze Pads (50 per pack) Infant Quickheel Lancets (Box of 50) Lancets (100 per pack) Microvette Tubes (Box of 100) Screening Forms (50 per pack) Tube Labels (50 per packet) SHIPPING SUPPLIES (Non-Medicaid Only) Bio-hazard Mailing Bags (Maximum of 5) Fiberboard Cartons (Maximum of 10) Styrofoam Boxes (Maximum of 10) Venous Mailing Tubes (Maximum of 10) LITERATURE (Supplies may be limited) About Lead Abatement in the Home ­ English About Lead Abatement in the Home ­ Spanish About Your Child's Lead Level ­ English About Your Child's Lead Level ­ Spanish Children's Lead Levels ­ A Guide for Parents I Can Stay Safe/Lead Tale ­ English I Can Stay Safe/Lead Tale ­ Spanish Keep Your Children Safe ­ English Lead and Pregnancy ­ English Lead and Pregnancy ­ Spanish Lead and Pregnancy ­ Color ­ English Lead and Your Child's Diet ­ English Lead and Your Child's Diet ­ Spanish Lead Levels in Children ­ English
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UNIT Pack Box Pack Box Pack Box Pack Packet UNIT Each Each Each Each UNIT Each Each Each Each Each Each Each Each Each Each Each Each Each Each

QUANTITY

QUANTITY

QUANTITY

INDIANA STATE DEPARTMENT OF HEALTH
State Form 53546 (R / 9-08)

LITERATURE - Continued (Supplies may be limited) Lead Poisoning at Home Lead Campaign Brochures Lead Campaign Postcard ­ African American Boy Lead Campaign Postcard ­ Black and White Photo Lead Campaign Postcard ­ Crying Child Lead Campaign Postcard ­ Hispanic Girl Lead Campaign Postcard ­ Laughing Boy Lead Campaign Posters Lead Paint Safety ­ A Field Guide ­ HUD (Limit 2) Learn About Protecting Your Child from Lead Maintaining A Lead Safe Home ­ English (Limit 1) Maintaining A Lead Safe Home ­ Spanish (Limit 1) Managing Blood Lead Levels
Managing Elevated Blood Lead Levels Among Young Children ­ CDC (Limit 1)

Medical Management Recommendations Chart My Book/Stay Safe Coloring Book ­ English My Book/Stay Safe Coloring Book ­ Spanish
Preventing Lead Poisoning in Young Children ­
CDC 2005 (Limit 1)

Protect Your Child from Environmental Hazards Protect Your Child from Lead ­ English Protect Your Child from Lead ­ Spanish
Screening Young Children for Lead Poisoning ­ CDC 1997 (Limit 1)

Stay Safe Calendar ­ Coloring ­ English Stay Safe Calendar ­ Coloring ­ Spanish Stay Safe Calendar ­ Photo We Wonder Stay Safe from Lead ­ English We Wonder Stay Safe from Lead ­ Spanish We Wonder Stay Safe from Lead ­ Leader's Guide ­ English We Wonder Stay Safe from Lead ­ Leader's Guide ­ Spanish What Everyone Should Know About Lead Poisoning ­ English What Everyone Should Know About Lead Poisoning ­ Spanish What You Should Know About Lead in Water What You Should Know About Your Child's Blood Lead Level

UNIT Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each

QUANTITY

For tracking purposes, please explain reason(s) for large quantities ordered:

FOR OFFICE USE ONLY (Do not go below this line) Date Order Received: (mm/dd/yyyy) Date Order Forwarded: (mm/dd/yyyy)
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