Alcohol-Based Hand Rub Dispenser Request

Name

Position/Title

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.

The requested dispenser will be secured in a wall- or surface-mounted bracket to prevent tipping or spilling product.

The capacity of the requested dispenser is 41 ounces or less.

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.

The request location is at least 48 inches (4 feet) from any other dispensers.

The request location is not on a door or inside an elevator.

The request location is in a corridor at least 72 inches (6 feet) wide.

The request location is in a patient room with a door, and there are no other dispensers present in the room.

If the request location is in a carpeted area, there is an automatic fire protection system (sprinklers).

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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