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Public Health Office Depot Order Form
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Please use a different form for each employee ordered for
Name of Staff Receiving Supplies
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Staff Phone Number
Building Location
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-- Select One --
108A
108B
109B
116A
116B
212
MTU - Newcastle
WIC - Rocklin
Tahoe
Program Fund Code
*
-- Select One --
CH 2 - Communicable Disease
CH 4 - MCAH
CH 5 - Immunizations
CH 9 - Tuberculosis
CH 10 - Targeted Case Management
CH 11 - PH/General Nursing
CH 15 - Tobacco
CH 16 - AIDS/HIV
CH 18 - Vital Statistics
CH 19 - Bioterrorism
CH 20 - City Readiness Initiative
CH 21 - BT Level B
CH 22 - California Children Services
CH 23 - Medical Therapy Unit
CH 24 - CHDP
CH 27 - Medical Marijuana
CH 29 - Pan Flu
CH 30 - HPP
CH 31 - Oral Health
CH 32 - SNAP
CH 33 - Whole Person Care
W101 - WIC Admin
W102 - WIC Nutritional Assistance
W103 - WIC Client Services
W104 - WIC Breastfeeding Support
W105 - WIC Breastfeeding Peer Counseling
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