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PPE Data Summary

I Provider number 153105
acknowledge that I received the following amount of supplies:

0 Bleach 0 Toilet Paper
0 Disinfectant Wipes 2 Gloves
0 Hand Soap 5 Cloth Masks
1 Hand Sanitizer 5 Disposable Masks
0 Paper Towels 0 No-Touch Thermometer
Child 01:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Child 02:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Child 03:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Child 04:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Additional children & their ages

17 year old


Caregiver’s Signature or Mark: ______________________________________________________________________________

Delivered on August 3, 2020 at 2:10 PM

Caregiver’s zipcode:

98032

Organization making the delivery: Sisters in Common