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GARDLINE MARINE SCIENCES LTD

SPARES / STORES REQUISITIONS FORM GL31A


VESSEL Triton DEPT Deck - Medical REQ NO TD072.16
DATE 19.04.2016 NEXT P.O.C Singapore E.T.A

This Form to be emailed to Superintendent & Purchasing department.

FOR OFFICE USE ONLY


Makers Name/Description/Product/
Item Quantity Quantity Quantity
Part No’s/Reference No./ Item Price
No. Onboard Requested Sanctioned
Pack Size, etc
1 Glyeryl Trinitrate transdermal patches 0 2 Switch to Rp.400.000
5mg x2 uromucosal
spray
2 Frusemide / Furosemide 10mg in 1ml 0 2 Swtich to Rp.25,000
inj. oral drug
(2ml ampoule) (Furosemide
40mg)
3 Phytomenadione (Vitamin K1) 5 5 Rp.125.000
paediatric injection (0.2ml ampoule) Exp May-16
4 Atenolol 50mg tablets 0 28 Rp.40.000
5 Prochlorperazine maleate 3mg buccal 25 25 Switch to Rp.50.000
tablets metocloprami
d tab 10 mg
6 Hyoscine hydrobromide 0.3mg 90 60 Rp.300.000
or Cinnarizine 15mg tablets Exp Jun-16
7 Hyoscine butylbromide 10mg 10 46 Rp180.000
8 Diazemuls injection 5mg per ml (2ml 2 5 Rp.150.000
ampoules) Exp Jul-16
9 Diazepam rectal dispenser 10mg in 0 5 Rp.200.000
2.5ml
10 Tetanus Immunoglobulin ampoule for 0 1
injecton
11 Benzoic ointment BP 50mg (Benzoic 3 3 Rp.30.000
acid 6%; salicylic acid 3%, in Exp May-16
emulsifying ointment 15g)
12 Silver Sulphadiazine 1% cream 50g 0 2 Rp.150.000
tube
13 Neomycin sulphate 0.5% 0.5ml 0 20 Rp.160.000
antibiotic eye drops (minim single dose)
14 Dexamethasone sodium phosphate 0 20 Rp.160.000
0.1% 0.5ml anti-inflammatory eye drops
(minim single dose)
15 Lignocaine / Lidocaine subcutaneous 20 5 Rp.100.000
injection hydrochloride 1% 50mg in 5ml Exp Jun-16
amps for injection
16 Paraffin gauze dressing (10cm x 10cm) 20 20 Rp.500.000

Author DPA DPA


Approved MARINE MARINE
Issue No. 1 2
Issue Date 11/09/13 05/02/14
Revision No. 0 1
GL31A Spares / Stores Requisitions Form – Page 1 of 2
Add Row

The Items listed contain a full and complete Master/Chief Engineer


description.
I confirm the quantities are currently onboard Signature      
and are correct as listed.
Name T. Silvam

Office Use Only Delivery Onboard


Actioned Date
Date Required                  
By Received
Approved
Date Actioned             Checked By      
By
Date
      Method       Signature      
Despatched:

Author DPA DPA


Approved MARINE MARINE
Issue No. 1 2
Issue Date 11/09/13 05/02/14
Revision No. 0 1
GL31A Spares / Stores Requisitions Form – Page 2 of 2

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