Delaware Emergency Management Agency / KI Distribution Center / / /
Position
Driver / Program Manager / /
Product
HEALTH/PHARMACY SPECIALIST WILL DO SO WHEN THEY DISPENSE YOUR TABLETS / Per Dose Days Tablets / PLEASE COMPLETE YELLOW COLUMN ONLY BY PROVIDINGTHE NUMBER OF ADULT AND CHILDREN RESIDING AT THIS ADDRESS For Official Use Only Tablets / Exp / Potassium Iodide / KI Tablets / Thyrosafe / /
Potassium Iodide (KI) Request Form (Instructions: Please Complete Form and Bring with you to KI Distribution Center - Please PRINT CLEARLY - Thank you!) Name: ____________________________________________________________