MATERIALS MANAGEMENT PRODUCT REQUEST FORM

Logistics Management PRODUCT REQUEST FORM

REQUEST #: Hit Counter

REQUESTER :	PHONE:
DEPARTMENT:	MAIL CODE:

SECTION I:

TYPE OF PRODUCT	REQUEST TYPE	REQUEST WOULD
Medical disposable	New item to stock	Duplicate existing product
Non-Med Equipment	Non-stock to stock	Standardize
Lab Disposable	New item non-stock	Replace
Dental Disposable	Vendor direct (Special)	Add new
Office Supplies	Delete product
Other	Vendor change

PRIORITY: Essential Important Desirable

Does this item replace or duplicate a current stock item? Yes No If Yes: Warehouse #: Vendor #:

What justifies the introduction of this product?	New Service	Improved Service
Code/Policy Compliance	Cost Savings/Avoidance	Increased Usage
Improved safety	Change to or from Disposable/ Reusable	Other

Please include a written justification for the introduction of this product. What is it used for, Cost Savings, Improved service, etc. Include the justification with this form when faxing or mailing to Logistics Management. Fax 679-1993 or Mail: MC2012 email PDF: kgrady@uchc.edu

Department Manager's (or Physician's) Signature: __________________________________________ Date: __/__/__

SECTION II:

PRODUCT INFORMATION:

Description: Vendor:

Manufacturer: Catalog Number:

Preferred Unit of Measure:

Available Unit of Measure: Price: or
Price: or Price:
Number Per Unit:

Contract Source: Novation: Other:

Is current product being used on a contract: Yes No
Contract Source: Contract Expires On:

Custom Made: Yes No Monthly Usage: Lead Time (days):

Product Information:

1. Does product contain Latex: Yes No

2. Will product have contact with or be used to inject/extract blood, body fluids, (needles, gloves, IV's) etc.: Yes No

*3. Is this product department specific: Yes No 4. Is product a patient charge item: Yes No

5. Does product require special handling/storage: Yes No If "Yes", elaborate:

* If "No", please attach a listing of other Hospital or Clinical units that would use this product.

Value Analysis Manager's (or Designee) Signature: _________________________________________ Date: __/__/__

Materials Manager's (or Designee) Signature: _________________________________________ Date: __/__/__

If item #2 is checked: Epidemiology Manager's Signature: ______________________________________ Date: __/__/__

SECTION III:

INVENTORY:

Product should be considered for: Warehouse stock: Prime Vendor: Vendor Direct:

Should product be added to the PAR system: Yes No
If "Yes", please list Hospital and Clinical Units affected.
If PAR or Department Specific: FRS Account Charged: __-__________ Warehouse/PAR Ship-To Account: _________

Warehouse Number Assigned to New Product: _____________ Unit of Issue from warehouse: _________

University Director of Logistics Management (or Designee) Signature: ____________________________________________ Date: __/__/__

Once completed, please print the form and Fax (x-1993) Logistics Management - Value Analysis or Mail MC2012 (FB023)