EMS Equipment Request

Please complete the form below to request the use of the MEASEY Program’s EMT/EMS equipment. Dr. Dickinson and Mr. Wurster will coordinate approval and dispersal of the equipment upon receiving your submission to issue approval or obtain follow up information related to your request. Please note submission of form does not guarantee that equipment will be available for loan.

Name Name First Last
Email Address
Phone Number Phone Number - ### - ### ####
Please enter the date(s) you need the equipment and what you will be using it for.
Equipment Pick-Up Date Equipment Pick-Up Date / MM / DD YYYY
Equipment Return Date Equipment Return Date / MM / DD YYYY
Please check off all equipment you are requesting to borrow. For items that require you to specify the quantity, please do so in the following question.

Please check off all equipment you are requesting to borrow. For items that require you to specify the quantity, please do so in the following question. Adult CPR Manikin (include quantity needed below*) Infant CPR Manikin (include quantity needed below*) Advanced airway manikin OB manikin AED Trainer (include quantity needed below*) Stop the Bleed trainer Bag valve mask (include quantity needed below*) Oxygen bag Bandaging supplies Splint(s) Other - please specify below*
If you selected any equipment that requires a quantity to be specified or the "Other" option in the question above, please do so here.
I understand that I am not permitted to remove this equipment from the Jordan Medical Education Center.

I understand that I am not permitted to remove this equipment from the Jordan Medical Education Center. Yes No