PURCHASE REQUISITION FORM Purchasing Department YARSI Hospital

Complete the information and obtain approvals below. Forward the completed and approved form to the Purchasing Department (RSGM Fl.3). Forms that are not approved or incomplete will be
returned to the applicant.

APPLICANT INFORMATION
NAME Edvika magdalena REQUEST NUMBER :

DEPARTMENT Penujang Medis REQUEST DATE : 16-Aug-18

POSITION PJS Rehabilitasi Medik REQUIRED DATE :

BMHP 6 BULAN INSTALASI REHABILITASI MEDIK

NO System Number Brand Type QTY UoM Remarks

1 Seliruh Staf Rehabilitasi

Masker Hijab 72 BOX Medik

2 Seliruh Staf Rehabilitasi

Masker Laki Laki 73 BOX Medik
Seliruh Staf Rehabilitasi
3 Medik
Handskun ( M ) 74 BOX

4 Setiap Wastafel Instalasi

Hand Soap 192 L Rehabilitasi Medik
Setiap Rungan Rehabilitasi
5 Medik
Handrub 288 L

6 Di setiap Alat MODALITAS

Tisu Wajah 864 BOX

7 Setiap Toilet
Tisu Toilet 432 ROL

8 Untuk Alas bantal Pasien

Tissue Towel 144 ROL
Untuk modalitas tens dan
9 ES
Micropore 5 cm 432 ROL

10 Untuk modalitas tens dan

Micropore 2,5 cm 433 ROL ES
Untuk modalitas ES, ESWT,
11 US , LASER
gel ultrasound 216 L
Untuk Peyimpanan Jarum
12
safety box medis 288 BOX bekas pakai
Untuk Membersikan Alat
13 Modalitas
Alkoholol 95 % 12 L

14 R.GYM
Batrai A3 96 L
Special Instructions :

Filled by user
Created By : *Approved By : **Knowing By : ***Approved By :

Applicant Applicant's Manager GA Manager

Date : Date : Date : Date :

Notes :
*For request with estimate total value more than 1 million rupiah must be approved by Applicant's Manager
**For request of item in the form of assets must be knowing by GA Manager
***For request with value more than 15 million rupiah must be approved by General Manager/Related Director

Filled by Purchasing Department :

Received By : Approved By :

Purchasing Staf Purchasing Manager

Date : Date :

Form PURCHASING/PR01/2018 -For Internal Use Only-

 Stok yang harus Tersedia
No Nama barang
1 hari 1 minggu 1 bulan 6 bulan
1 Masker Hijab 1/2 BOX 3 BOX 12 BOX 72 BOX
2 Masker Laki Laki 1/2 BOX 4 BOX 13 BOX 73 BOX
3 Handskun ( M ) 1/2 BOX 5 BOX 14 BOX 74 BOX
4 Hand Soap 4L 32 L 192 L
5 Handrub 2L 12 L 48 L 288 L
6 Tisu Wajah 6 box 36 BOX 144 BOX 864 BOX
7 Tisu Toilet 3 Rol 18 ROL 72 ROL 432 ROL
8 Tissue Towel 1 ROL 6 ROM 24 ROL 144 ROL
9 Micropore 5 cm 3 ROL 18 ROL 72 ROL 432 ROL
10 Micropore 2,5 cm 3 ROL 19 ROL 73 ROL 433 ROL
11 gel ultrasound 1L 6L 36 L 216 L
12 safety box medis 2 BOX 12 BOX 46 BOX 288 BOX
13 Alkoholol 95 % 500 ML 2 L 12 L
14 Batrai A3 4 Buah 16 Buah 96 L