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Annual Usage Report and Expired Inventory Order Form

 
Thank you for taking the time to complete the Annual Usage Report and Expired Inventory Order Form. Each year we ask that you complete this form no later than July, so we can continue to improve the kit and replace the supplies as they expire. If you have any questions or concerns please contact Eric Hicken at 609-633-7777.

 
* Required Fields
School/District Info
* School District:
* School Name:
* Address:
* City:
* State: * Zip:
* Person Completing the Report:
* Contact Phone:
* Contact Email :
** Update only if information on record has changed
** Location of Kit in the School:
** Number of Schools in your District:
** Location of the Kit:
** Emergency Contact Name:
** Emergency Contact Phone


Expired Inventory Order Form
Qty Description  
2 Glucose Tubes
2 D Cell Batteries
2 AA Cell Batteries
2 Hydrogen Peroxide
4 Saline - 500ml


Acceptance Agreement

* I hereby agree to the following terms and conditions of accepting the Emergency School Kits from the New Jersey Department of Health and Senior Services.  

  • Replacement of supplies used by staff during the school year
  • Submission by July 15th of each year, the annual usage report.
  • Facilitate any necessary physician orders for the utilization of all supplied medical equipment
  • Register the kit with the Department of Health and Senior Services for 24 hour access
  • If the school closes or administration no longer can participate in the program then the school is responsible for contacting the Department and returning the bag for redistribution.  

 
   
 

 

Department of Health and Senior Services
P. O. Box 360, Trenton, NJ 08625-0360
Phone: (609) 292-7837
Toll-free in NJ: 1-800-367-6543
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Last Modified: Tuesday, 10-Jun-08 11:16:39