Administering Files, Records, and Grants

1

2

JOHNSON MEDICAL CLINIC MEDICAL SUPPLY RECEIPT AND INVENTORY FORM

INCIDENT NAME INCIDENT#:

Part A. Supplies received from: Date: / /

Unit ID #: Agency: Name:

(Always markers should be used to indicate each equipment/supplies)

Part B. Supplies Received by:

Name/Sign: Rank/Position:

Item No.	Description of Item (All Entries must be Printed)	Manufacturer	Unit	Cost Per Item	Stock Quantity	Inventory Value
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

*Unit-list the item’s measurable description e.g. gm, gauge, ml, doz, bag, etc.

Form Distribution: (Carbon Paper should be used)

Original Copy- (Should be given to the Medical Administrative Specialist)

A copy should be given to the Supplier.

*Only Original Form Listings will be used for Incident Re-imbursement of any Equipment/Supply.