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Report an Issue
Alcohol-Based Hand Rub Dispenser Request
Name
Position/Title
Email
Phone # (Example: 9196842794)
Building Name
Unit/Department
Specific Location
All existing dispensers within the department/unit, to include wall-mounted and hand-pump types, are secured in brackets to prevent tipping or spilling product.
- Select -
Yes
No
The requested dispenser will be secured in a wall- or surface-mounted bracket to prevent tipping or spilling product.
- Select -
Yes
No
The capacity of the requested dispenser is 41 ounces or less.
- Select -
Yes
No
The request location is at least 1 inch from any electrical equipment or other ignition sources, and not within 1 inch vertically if being mounted on the wall above any electrical equipment or other ignition sources.
- Select -
Yes
No
The request location is at least 48 inches (4 feet) from any other dispensers.
- Select -
Yes
No
The request location is not on a door or inside an elevator.
- Select -
Yes
No
The request location is in a corridor at least 72 inches (6 feet) wide.
- Select -
Yes
No
N/A
The request location is in a patient room with a door, and there are no other dispensers present in the room.
- Select -
Yes
No
N/A
If the request location is in a carpeted area, there is an automatic fire protection system (sprinklers).
- Select -
Yes
No
N/A
Quantity of wall-mounted dispensers (41 ounces) already present within the department/unit:
Quantity of hand-pump dispensers (13.5 ounces) already present within the department/unit:
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