Embroidered Lab Coat Fitting Form
Please fill out all highlighted fields.
BASIC INFORMATION TO BE COMPLETED BY THE LAB MEMBER
Last Name, First Name, Middle Initial:
UCSD E-mail:
Primary PI:
Office or Lab Phone:
*Affiliation: (Post-Doc, Staff, Grad. Student, etc.)
Department you are affiliated with:
Building Name (for delivery) :
Lab Delivery Room Number (include bay) :
THE FOLLOWING SHOULD BE WRITTEN EXACTLY AS YOU WANT IT TO APPEAR ON YOUR LAB COAT. EMBROIDERY CANNOT BE IN ALL CAPS.
NOTE: All abbreviations and titles need a period. (e.g. M.D. not MD)
PROFESSIONAL NAME AS IT IS TO BE
EMBROIDERED ON LAB COAT
WHITE COATS: 25 CHARACTERS MAX
FR COATS: 22 CHARACTERS MAX
I, _________________________________________________________ (PRINT NAME) VERIFY THE
FOLLOWING:
1.
2.
3.
THE ABOVE-NAMED INDIVIDUAL IS EMPLOYED BY THE LAB LISTED ABOVE AND WILL WORK IN THE LAB
FOR AT LEAST THE NEXT SIX MONTHS
MEETS THE CRITERIA* FOR THE PPE PROGRAM
THE EMBROIDERY LISTED ABOVE IS ACCEPTABLE AND LEGIBLE.
SIGNATURE:__________________________________________________________________DATE:_________
*AFFILIATION CRITERIA: RESEARCHERS EMPLOYED BY UC SAN DIEGO, INCLUDING PAID UNDERGRADS, GRAD
STUDENTS AND POST-DOCS
EMBROIDERED LAB COAT AND SAFETY GLASSES INFORMATION
(TO BE COMPLETED BY PPE STAFF AT YOUR FITTING SESSION)
Safety Glasses
2 (Snap Cuff Male)
Style 1:
SIZE
QTY
3 (Snap Cuff Female)
SIZE
QTY
4 (Knitted Cuff)
SIZE
QTY
5 (Button Male/Unisex)
SIZE
QTY
6 (Button Female)
SIZE
QTY
Style 2:
7 (FR Male)
SIZE
8 (FR Female)
QTY
SIZE
Date of Fitting
Loaner
Coat? Y/N
Rev 5-6-2015
Size
QTY
9 (Barrier Male)
SIZE
QTY
Verified in CHUA/LHAT?
Declined
Loaner Coat?
(Lab Member Intial)
10 (Barrier Female)
SIZE
QTY
11 (Traditional Male)
SIZE
QTY
12 (Traditional Female)
SIZE
QTY
Safety Glasses/Loaner Coat Entered into
CHUA/LHAT?
Reviewed PPE
PPE Fitting Staff Signature
Protocol?