PROVIDER REQUEST FOR SUPPLIES MARION COUNTY
State Form 53547 (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 INFORMATION Provider Number: 50675 Date: (mm/dd/yyyy) Name of Agency: Contact Name: Marion County Health Department City: Street Address: (UPS will NOT deliver to PO Box) 3838 N. Rural St. Indianapolis State: ZIP Code: Agency Phone Number: (Including Area Code) IN 46205 317.221.2441 Email Address:
SCREENING SUPPLIES (Non-Medicaid Only) Adhesive Bandages (100 per pack) Alcohol Preps (Box of 100) Gauze Pads (50 per pack) 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 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
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UNIT Pack Box Pack UNIT Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each Each
QUANTITY
QUANTITY
INDIANA STATE DEPARTMENT OF HEALTH
State Form 53547 (R / 9-08)
LITERATURE - Continued (Supplies may be limited) 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
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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