Code Lavender Cart Request Form

Date Requested:

Start Time:

1. Person Requesting Code Lavender: (Unit Director, Manager, Supervisor)

Name:

Phone Number:

2. Department/Unit Involved:

3. Reason for Request:

Those Most Affected: (Shift(s), Days vs. Nights)s

4. Estimated Number of People in Department/Unit:

5. What Services Would Most Benefit Your Department/Unit?

Cart with comforting snacks, beverages, etc.

Post-Traumatic Stress Management

Other

If “Other” was selected for Question 5, please provide further clarification.

6. Duration of Event (in Hours up to 72 hours):

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Options to Request an Appointment