1. Name of the department: Fill in the name of the department you are working in and make sure it is accurate.
2. Provider Information: Fill in the name, address, contact number and other relevant information of the provider.
3. Responsible person information: Fill in the name, title, contact phone number and other relevant information of the person in charge of the department.
4. Equipment information: Fill in the original sputum aspirator model, number and other details, which can be found on the equipment or in the equipment manual.
5. Reason for Replacement: Briefly explain why the aspirator needs to be replaced, e.g., the device is damaged, outdated, not functioning properly.
6. Date of request: the date on which the request form was completed.
7. Signature: Signature of the applicant or head of department in the appropriate place.
Please note that the specific form format and requirements may vary from one healthcare organization to another, and you may consult with the relevant personnel responsible for equipment maintenance or procurement to ensure that the correct information is filled in.