FACILITY NAME / CUSTOMER CONTACT
CUSTOMER ADDRESS
CUSTOMER PHONE # / CUSTOMER EMAIL
CASE MED REP / DATE INITIATED

MF # 223 Rev. C

PREFERENCES FOR CASE CART SELECTION

Open Case Cart

Single Bay / Double Bay / Tall 3 Bay Shelving / Shelves: Adjustable Pull-out (Option)

Standard Closed Case Carts

Single / Deep/Wide / Adjustable Shelves
Double / Door Lock (Option) / Pull-out Shelves (Option)

Tall Closed Case Cart

Tall Standard / Supply Cart / Adjustable Shelves
Tall Deep/Wide / Door Lock (Option) / Pull-out Shelves (Option)

Wheels

Polyurethane / Directional / Number of Locking Wheels : ______
Rubber (Gray) / Non-Directional

Options

Disposition Monitor / Extra Shelf / Bar Code Tracking
Supply Bins / Puller & Hitch / RFID
Transport within Facility / External Transport
Hospital Use / Clinic Use

Needs Assessment

Questions for Case Cart Selection

1.  Open or closed? ______

2.  Tall or wide?______

3.  Shelving?______

4.  Dimensions: smallest doorway to pass through in OR? ______

5.  Dimensions: smallest doorway to pass through in SPD? ______

6.  Dimensions: width of hallway? ______

7.  Maximum cart height required by staff? ______

8.  Clearance needed to clear corners? ______

9.  How does facility plan to clean? ____ Manual ____ Cart Washer ___ Other

10. What product does facility plan to use for cleaning carts? ______

Questions for Transport of Carts

1.  If transported by van, what is height and width of door opening? ______

2.  How many carts can be placed in van? ______

3.  How does facility plan to secure cart during transport in van? ______

4.  Does facility have a way to differentiate “clean” and “used” items? ______

Note: Wheels may be polyurethane or rubber, directional or non-directional. Rubber wheels are quieter, but wear and may leave streaks on the floor. Polyurethane wheels are more durable. A suffix following the part ID will denote the type of wheel chosen.

PD-Polyurethane, Directional (rigid front wheels)

PN- Polyurethane, Non-Directional (swivel)

RD- Rubber, Directional (rigid front wheels)

RN- Rubber, Non-Directional (swivel)

Issued By: M. Frieze
First Issue Date: 1/22/2015
File: QC\Master Forms/Marketing/MF # 223
CASE CART FORM.doc / Revision No.: C
Changed by: MF Revision Date: 8/16/2016
Verified & Approved by: TL Date: 7/28/2016