UMHS Supply Requisition Form

Date Requesting: Date Requesting: / MM / DD YYYY
Name of Person Requesting: Name of Person Requesting: First Last
Center/Office Location: (IE: Boardman CCP or Boardman Little Pirates or Boardman All Classrooms)
Date Expected to Pick up: Date Expected to Pick up: / MM / DD YYYY

Diapers & Diaper Wipes:
Diapers & Diaper Wipes:	1 Sleeve/Package	1 Box	2 Boxes
Size 1 Diapers	Size 1 Diapers1 Sleeve/Package	Size 1 Diapers1 Box	Size 1 Diapers2 Boxes
Size 2 Diapers	Size 2 Diapers1 Sleeve/Package	Size 2 Diapers1 Box	Size 2 Diapers2 Boxes
Size 3 Diapers	Size 3 Diapers1 Sleeve/Package	Size 3 Diapers1 Box	Size 3 Diapers2 Boxes
Size 4 Diapers	Size 4 Diapers1 Sleeve/Package	Size 4 Diapers1 Box	Size 4 Diapers2 Boxes
Size 5 Diapers	Size 5 Diapers1 Sleeve/Package	Size 5 Diapers1 Box	Size 5 Diapers2 Boxes
Size 6 Diapers	Size 6 Diapers1 Sleeve/Package	Size 6 Diapers1 Box	Size 6 Diapers2 Boxes
Size 7 Diapers	Size 7 Diapers1 Sleeve/Package	Size 7 Diapers1 Box	Size 7 Diapers2 Boxes
Diaper Wipes	Diaper Wipes1 Sleeve/Package	Diaper Wipes1 Box	Diaper Wipes2 Boxes

Paper Products:
Paper Products:	5 Packages/Rolls	10 Packages/Rolls	1 Box
Trifold Paper Towels	Trifold Paper Towels5 Packages/Rolls	Trifold Paper Towels10 Packages/Rolls	Trifold Paper Towels1 Box
Toilet Paper	Toilet Paper5 Packages/Rolls	Toilet Paper10 Packages/Rolls	Toilet Paper1 Box
Facial Tissue Box	Facial Tissue Box5 Packages/Rolls	Facial Tissue Box10 Packages/Rolls	Facial Tissue Box1 Box

Gloves:
Gloves:	1 Box	2 Boxes	3 Boxes	4 Boxes
Small Nitrile Gloves	Small Nitrile Gloves1 Box	Small Nitrile Gloves2 Boxes	Small Nitrile Gloves3 Boxes	Small Nitrile Gloves4 Boxes
Medium Nitrile Gloves	Medium Nitrile Gloves1 Box	Medium Nitrile Gloves2 Boxes	Medium Nitrile Gloves3 Boxes	Medium Nitrile Gloves4 Boxes
Large Nitrile Gloves	Large Nitrile Gloves1 Box	Large Nitrile Gloves2 Boxes	Large Nitrile Gloves3 Boxes	Large Nitrile Gloves4 Boxes
X-Large Nitrile Gloves	X-Large Nitrile Gloves1 Box	X-Large Nitrile Gloves2 Boxes	X-Large Nitrile Gloves3 Boxes	X-Large Nitrile Gloves4 Boxes
Small Food Gloves	Small Food Gloves1 Box	Small Food Gloves2 Boxes	Small Food Gloves3 Boxes	Small Food Gloves4 Boxes
Medium Food Gloves	Medium Food Gloves1 Box	Medium Food Gloves2 Boxes	Medium Food Gloves3 Boxes	Medium Food Gloves4 Boxes
Large Food Gloves	Large Food Gloves1 Box	Large Food Gloves2 Boxes	Large Food Gloves3 Boxes	Large Food Gloves4 Boxes
X-Large Food Gloves	X-Large Food Gloves1 Box	X-Large Food Gloves2 Boxes	X-Large Food Gloves3 Boxes	X-Large Food Gloves4 Boxes

Cleaning Products:
Cleaning Products:	1	2	3
Nutra Care Floor Cleaner	Nutra Care Floor Cleaner1	Nutra Care Floor Cleaner2	Nutra Care Floor Cleaner3
Gallon Bleach	Gallon Bleach1	Gallon Bleach2	Gallon Bleach3
Gallon Laundry Soap	Gallon Laundry Soap1	Gallon Laundry Soap2	Gallon Laundry Soap3
Washing Machine Cleaner	Washing Machine Cleaner1	Washing Machine Cleaner2	Washing Machine Cleaner3
Carpet Cleaning Solution	Carpet Cleaning Solution1	Carpet Cleaning Solution2	Carpet Cleaning Solution3
Gallon Lime Away	Gallon Lime Away1	Gallon Lime Away2	Gallon Lime Away3
Toilet Bowl Cleaner	Toilet Bowl Cleaner1	Toilet Bowl Cleaner2	Toilet Bowl Cleaner3
Virex TB Disinfectant	Virex TB Disinfectant1	Virex TB Disinfectant2	Virex TB Disinfectant3
Pkg Bactive Sani Wipes	Pkg Bactive Sani Wipes1	Pkg Bactive Sani Wipes2	Pkg Bactive Sani Wipes3
Blue Ecolab Apex Presoak	Blue Ecolab Apex Presoak1	Blue Ecolab Apex Presoak2	Blue Ecolab Apex Presoak3
White Ecolab Apex Power Det.	White Ecolab Apex Power Det.1	White Ecolab Apex Power Det.2	White Ecolab Apex Power Det.3
Green Ecolab Apex Rinse Add.	Green Ecolab Apex Rinse Add.1	Green Ecolab Apex Rinse Add.2	Green Ecolab Apex Rinse Add.3
Scotch Brite Griddle Liquid	Scotch Brite Griddle Liquid1	Scotch Brite Griddle Liquid2	Scotch Brite Griddle Liquid3
Ajax	Ajax1	Ajax2	Ajax3
Biodet ND32- Lemon	Biodet ND32- Lemon1	Biodet ND32- Lemon2	Biodet ND32- Lemon3
Gallon Super Trump Deterg.	Gallon Super Trump Deterg.1	Gallon Super Trump Deterg.2	Gallon Super Trump Deterg.3
Gallon LOW Temp Sanitizer	Gallon LOW Temp Sanitizer1	Gallon LOW Temp Sanitizer2	Gallon LOW Temp Sanitizer3
Gallon HIGH Temp Sanitizer	Gallon HIGH Temp Sanitizer1	Gallon HIGH Temp Sanitizer2	Gallon HIGH Temp Sanitizer3
Simple Green	Simple Green1	Simple Green2	Simple Green3

Trash Bags:
Trash Bags:	1 Roll	2 Rolls	5 Rolls	1 Box
Small Trash Bags	Small Trash Bags1 Roll	Small Trash Bags2 Rolls	Small Trash Bags5 Rolls	Small Trash Bags1 Box
Large Trash Bags	Large Trash Bags1 Roll	Large Trash Bags2 Rolls	Large Trash Bags5 Rolls	Large Trash Bags1 Box

Cleaning Materials:
Cleaning Materials:	1	2	3	4
Set of Cleaning Rags	Set of Cleaning Rags1	Set of Cleaning Rags2	Set of Cleaning Rags3	Set of Cleaning Rags4
Set of Wash Rags	Set of Wash Rags1	Set of Wash Rags2	Set of Wash Rags3	Set of Wash Rags4
Broom/Dust Pan Set	Broom/Dust Pan Set1	Broom/Dust Pan Set2	Broom/Dust Pan Set3	Broom/Dust Pan Set4
32 oz Spray Bottle	32 oz Spray Bottle1	32 oz Spray Bottle2	32 oz Spray Bottle3	32 oz Spray Bottle4
Mop Head Replacement	Mop Head Replacement1	Mop Head Replacement2	Mop Head Replacement3	Mop Head Replacement4
Mop Handle Replacement	Mop Handle Replacement1	Mop Handle Replacement2	Mop Handle Replacement3	Mop Handle Replacement4

Bathroom Supplies:
Bathroom Supplies:	1	2	3	1 Box
Pkg Toilet Seat Covers	Pkg Toilet Seat Covers1	Pkg Toilet Seat Covers2	Pkg Toilet Seat Covers3	Pkg Toilet Seat Covers1 Box
Foaming Hand Soap	Foaming Hand Soap1	Foaming Hand Soap2	Foaming Hand Soap3	Foaming Hand Soap1 Box
Pink Hand Soap (Gallon)	Pink Hand Soap (Gallon)1	Pink Hand Soap (Gallon)2	Pink Hand Soap (Gallon)3	Pink Hand Soap (Gallon)1 Box

Toothbrushing Supplies:
Toothbrushing Supplies:	1	5	10	25
Toothpaste	Toothpaste1	Toothpaste5	Toothpaste10	Toothpaste25
Preschool Toothbrushes	Preschool Toothbrushes1	Preschool Toothbrushes5	Preschool Toothbrushes10	Preschool Toothbrushes25
Infant/Toddler Toothbrushes	Infant/Toddler Toothbrushes1	Infant/Toddler Toothbrushes5	Infant/Toddler Toothbrushes10	Infant/Toddler Toothbrushes25
3oz Cups	3oz Cups1	3oz Cups5	3oz Cups10	3oz Cups25
5oz Drinking Cups	5oz Drinking Cups1	5oz Drinking Cups5	5oz Drinking Cups10	5oz Drinking Cups25

Health & Safety Items:
Health & Safety Items:	1 Box	2 Boxes	3 Boxes
Bleach Test Strips	Bleach Test Strips1 Box	Bleach Test Strips2 Boxes	Bleach Test Strips3 Boxes
Child Cabinet Locks	Child Cabinet Locks1 Box	Child Cabinet Locks2 Boxes	Child Cabinet Locks3 Boxes
Child Drawer Locks	Child Drawer Locks1 Box	Child Drawer Locks2 Boxes	Child Drawer Locks3 Boxes
Outlet Covers	Outlet Covers1 Box	Outlet Covers2 Boxes	Outlet Covers3 Boxes

Coffee/Tea:
Coffee/Tea:	1 Box	2 Boxes	3 Boxes
Coffee Pods	Coffee Pods1 Box	Coffee Pods2 Boxes	Coffee Pods3 Boxes
Tea Packets	Tea Packets1 Box	Tea Packets2 Boxes	Tea Packets3 Boxes
Creamer/Sugar	Creamer/Sugar1 Box	Creamer/Sugar2 Boxes	Creamer/Sugar3 Boxes

Paper/Ink:
Paper/Ink:	1	2	3	1 Box
Copy Paper	Copy Paper1	Copy Paper2	Copy Paper3	Copy Paper1 Box
Ink/Toner	Ink/Toner1	Ink/Toner2	Ink/Toner3	Ink/Toner1 Box

Ink/Toner Description:
Office Supplies: (List out Request)
Attach PO if Item is Specific:

Attach Files
Additional Notes: