DELAWARE PUBLIC HEALTH LABORATORY - SPECIMEN/SAMPLE COLLECTION KIT SUPPLIES REORDER FORM SECTION A (TO BE COMPLETED BY INDIVIDUAL PLACING ORDER. WHEN COMPLETE, FORWARD TO DPHL ADMINISTRATION) ORDER SUBMITTED BY (Check one): _____ DNREC - EMEB _____ USPS - DATE ORDER SUBMITTED:_______________________________ _____ 31st CST _____ FBI - I acknowledge these materials are only used for _____ DPH - ERMB _____ DSFS - restocking the assigned specimen collection kit. _____ DDA - _____ ODW SUBMITTER'S SIGNATURE: ______________________________ _____ DPH - EPI _____ Other-Specify: __________ SUBMITTER'S NAME (PRINTED):__________________________ DATE____________________ KIT/BAG NUMBER (Listed on Tag):______________ Incident Date, Location and Description: PERSON ISSUED KIT/BAG (Print name):___________________ _____________________________________________________ VENDOR NAME: Fisher Scientific _____________________________________________________ TELEPHONE#:__________ ACCOUNT#:__________________ _____________________________________________________ P.O./D.C.# :________________ _____________________________________________________ QUANTITY FISHER SCI. COST ITEM NEEDED VENDOR ITEM QUANTITY IN UNIT UNIT PER TOTAL What is this # EA ITEM CATALOG # DESCRIPTION A FULL KIT QTY. SIZE UNIT COST item used for? 1 ________ BP2484-100 Water, Sterile, 20 mL total 1 ea $24.57 $0.00 Swab/swip 100 mL (5 mL ea. collection Polybottle in 4 tubes) 2 ________ 19-130-4569 Sampling Kit Bag; 1 1 ea $19.40 $0.00 Sample kit Blue. ERGODYNE bag No.:13417 3 ________ 13-689-8 60 mL disposable 2 40 pk $38.64 $0.00 Liquids syringes, collection Luer-Lok tip; #309653 4 ________ NC9020395 Fittings Male luer 2 1 ea $28.00 $0.00 Liquids lock x 1/16" OD collection tubing Male Luer Lok X 1/2 Mini,Cole Parmer Instrument Co. 5 ________ 14-176-178 30" weighted extension 2 50 cs $59.53 $0.00 Liquids tubing (2 lengths), collection 1/8" OD x 1/32 in., Nalgene No.: 8050 0125 6 ________ 14-825-16F BD# 305180 - 16 2 12 cs $71.56 $0.00 Liquids G x 1 1/2 in. collection BD[tm] blunt fill needle (12/cs) 7 ________ 05-556-0 Sterile disposable 4 400 pk $30.98 $0.00 Liquids barrel pipettes, collection Individual 8 ________ 05-538-68 50mL Polypropylene 4 500 cs $184.78 0.00 Solids & liquids Tubes, Costar* collection No.:430921 9 ________ 05-719-337 Environmental 30 100 cs $22.07 $0.00 Sealing all Custody Seals, containers I-Chem No.:500 10 ________ NC9453418 Large Zipper Bags, 12 250 cs $84.34 $0.00 Secondary 13 x 18 in Containment Us Plastic Corp. No.:47856 11 ________ NC9375773 Small ZIPPER BAG 12 250 cs $24.22 $0.00 Secondary 6X6" 250/CS, containment US PLASTIC CORP - vials & tubes No.:48630 12 ________ 14-366B Stainless steel 2 12 cs $104.00 $0.00 Solids Spatula, 4 in. collection 13 ________ 14-429E Stainless Steel 2 2 pk $34.80 $0.00 Solids Spoon; 2..0/8.0mL, collection Bel Art No.:36729003 14 ________ 14-512-62 Plastic Sampling 1 25 cs $30.97 $0.00 Solids Spoon,Large, Bel collection -Art No.:H369480000 15 ________ 19-042-312 Protective Plastic 1 1 roll $32.71 $0.00 Maintain controlled Sheeting, 4 mil workspace - lessens clear, 10 x 100 ft contamination roll, Poly-Pro Inc 16 ________ 13-383C Waterproof Pen, 1 6 cs $15.00 $0.00 Marking specimens, 0.3mm; Black forms, etc. 17 ________ NC9000774 Medium Zipper Bags 4 500 cs $95.94 $0.00 Secondary 4mil 12 x 15" containment Us Plastic Corp No.:4839 18 ________ 22-281-659 Dacron Swabs dual 4 100 pk $63.52 $0.00 Swabs/Swipes swab, sterile, Collection plastic transport tube tamper-evident label 19 ________ 14-907-11 Dry Transport Swab, 4 50 pk $29.93 $0.00 Swabs/Swipes Double, White Cap, Collection Sterile Fb 20 ________ 14-905-86 Swab Amie Rnd Btm 4 50 pk $28.18 $0.00 Swabs/Swipes Cl Db, Starplex Collection Scientific Inc No.:SP130D 21 ________ NC9008334 Sterile, 2 x 2" 4 100 pk $13.05 $0.00 Swabs/Swipes guaze, 8 ply sponge, Collection Henry Schein Co No.:8902637 22 ________ NC9811706 5 mL vial w/ Screw 4 100 pk $65.00 $0.00 Swabs/Swipes Cap, Usa Scientific Collection Inc No.:1505-1000, 1000/cs, 100/pk 23 ________ 19-130-5668 Scissors, 1 12 cs $25.94 $0.00 Opening/changing Shears; Ferno containment Trauma No.:IM0012 24 ________ 13-812-26 hemostat style 2 4 cs $118.54 $0.00 Swabs/Swipes locking forceps, Collection Rochester-Pean Serrated Forceps, 6 1/4" Straight, 4/cs 25 ________ 09902 3" A-Frame Photo 2 1 pk 25.60 $0.00 Evidentiary Marker Numbered 1-15 collection markers Yellow (Lynne Peavey # 09902) 26 ________ 12-112 Metric/English Steel 2 1 ea $17.98 $0.00 Size comparision for Tape Measure evidentiary/COC 120 Inch, collection Cooper Group No.:2210MEX 27 ________ 13-374-10 Parafilm 2 1 roll $16.59 $0.00 Sealing tubes, 4" W x 125 ft. L vials, etc. roll, Pechiney Plastic Packaging No.:PM996 28 ________ 05-719-333 Custody Seal Labels 4 96 pk $21.20 $0.00 Labeling containers, Vinyl 2-1/2x2-5/16" tubes, vials, etc. I-Chem No.:503 29 ________ 05-719-482 Glass Sample Jar, 2 24 cs $44.67 $0.00 Liquids I-Chem #V220-0250; Collection Capacity: 8 oz (250mL) 30 ________ 05-719-149C Plastic Overpack, 2 24 cs $55.66 $0.00 Liquids HDPE Wide Mouth Collection 500mL Closure 53-400 I-Chem #312-0500 31 ________ 08-888 Permanent Marker, 1 6 cs $17.52 $0.00 Marking specimens, Black, forms, etc. Waterproof Ink Section B: DPHL REMARKS: SHIPPING ____________ ____________________________________________ TOTAL _____________ Doc. #35-05-20/18/01/06