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Indiana State Department of Health

Environmental Public Health Home > Lead & Healthy Homes Program > Useful forms and Tools For Local Health Department Staff > Supply Order Form Supply Order Form

 (All Providers – both  Medicaid and non- Medicaid Eligible)

INDIANA LEAD AND HEALTHY HOMES PROGRAM

DIRECTIONS—PLEASE READ

Please complete all contact information. A Provider Number is required when ordering screening or shipping supplies. Enter quantities needed. Quantities shipped are subject to change based on availability. If you wish to email a supply request, please copy and paste the information below and send it to lead@isdh.in.gov.
Publications are available to anyone. Cut and paste titles into this form from the Publications Available link below.


Contact Information









Description

SCREENING SUPPLIES
(Providers Only)
Unit
Quantity
Adhesive Bandages (100 per pack)
pack
Alcohol Preps (pack of 100)
pack
Gauze Pads (50 per pack)
pack
Lancets (pack of 100)
pack
Filter Paper Cards (pack of 100)
box
Screening Form (A downloadable version is available at Form 14465)
LimsNet users do not need to send this form with the samples. LimsNet HelpDesk (317)921-5506
 
SHIPPING SUPPLIES
(Providers Only)
Unit
Quantity
Ziploc bags for filter paper cards
(pack of 100)
pack
Postage Paid Envelopes (each envelope can be used to ship six filter paper cards to the lab)
each
Venous Tube Labels (50 Labels per pack, Maximum of 1 pack)
pack
Venous Mailing Tubes (Maximum of 5)
each
 
PUBLICATIONS (Available to Everyone)
Cut & paste full title (including English/ Spanish) from Publications Available List to boxes below.
Unit
Quantity
each
each
each
each
each

When the order is complete click SUBMIT.

Please Allow 1 to 2 Weeks for Delivery