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["Annex 2: Financial Bid submission Form"]
["Name of Bidder:"]
["RFQ reference:"]
["Date:"]
["The Bidder is required to prepare the Price Schedule following the below format. The Price Schedule must include a detailed cost breakdown of all goods and related services to be provided. Separate figures must be provided for each functional grouping or category, if any."]
[]
["LOCATION 6 ( MUKALLA)"]
[]
["Medical Items","Quantity","Unit price","Total price"]
["Adhesive Tape 1 (12Ro/Bx) ",12]
["Adhesive Tape 1/2\" (24Ro/Bx) ",24]
["Aerosol Mask Adult ",5]
["Aerosol Mask Pediatric ",5]
["Alcohol Prep Pads (100Ea/Bx) ",1]
["Band Aids 3/4\"x3\" (100Ea/Bx) ",2]
["Bio Hazard Bag (500ea/bx) ",10]
["Cotton Tip Applicator, Non-Sterile  (100 Pkg/Bx) ",5]
["Exam Gloves, Small (100Ea/Bx) ",3]
["Exam Gloves, Small (300 ea/bx) ",2]
["Exam Gloves, Small Aloetouch (200  ea/bx) ",1]
["Exam Gloves, XSmall (200 ea/bx) ",1]
["Exam Gloves, XSmall (250 ea/bx) ",1]
["Nitrile (200 ea/bx) ",1]
["Exam Gloves,Medium (100Ea/Bx) ",8]
["Exam Gloves,Large (100Ea/Bx) ",8]
["Gauze Sponges, 2\"x2\" 4ply Unsterile  (200Ea/Bg) ",5]
["Gauze Sponges, 4\"x4\" 4ply Unsterile  (200Ea/Pkg) ",6]
["Hypodermic Needle 18 Ga, 1\"  (100Ea/Bx) ",100]
["Hypodermic Needle 21 Ga, 1 1/2\"  (100Ea/Bx) ",100]
["Hypodermic Needle 22 Ga. 1\"  (100Ea/Bx) ",100]
["Hypodermic Needle 23 Ga. 1\"  (100Ea/Bx) ",100]
["Hypodermic Needle 27 Ga. 1/2\"  (100Ea/Bx) ",300]
["Transparent Dressing 1.375\" x 1.375\" ",1]
["Trash Bag, 38x45 ",5]
["Hypodermic Syringe 03 cc (100Ea/Bx)  Luer Lok ",200]
["Hypodermic Syringe 05 cc (100Ea/Bx)  Luer Lok ",200]
["Sharps Container 5.4qts (needle  destroyer box) ",10]
["Tongue Depressor Adult Unsterile 500  ",500]
["Underpads, Disposables 17 x 24 100  ",100]
["Suction Tubing (50ea/bx) 50  ",50]
["Hypodermic Syringe 01 cc (TB Tip)  (100Ea/Bx) 200  ",200]
["Hypodermic Syringe 10 cc (100Ea/Bx) Luer Lok 300  ",300]
[" I.V. Extension Set w/Twin Inj. Sites ",100]
["Band Aids 3/4\" x 3\" (100Ea/Bx) ",3]
["PVP Triadine Solution 8 oz. ",5]
["I.V. Catheter 18 Ga. Needle (50Ea/Bx) ",10]
["I.V. Catheter 20 Ga. Needle (50Ea/Bx) ",100]
["I.V. Catheter 22 Ga. Needle (50Ea/Bx) ",250]
["I.V. Catheter 24 Ga. Needle (50Ea/Bx) ",250]
["I.V. Start Kit 100  ",100]
["Transparent Dressing 2\" x 3\" ",100]
["I.V. Injection Set w/ Twin Sites ",60]
["Oxygen Mask, Adult 5  ",5]
["Oxygen Mask, Pediatric 5  ",5]
["Oxygen Nasal Cannula 5  ",5]
["Oxygen Nasal, Pediatric 5  ",5]
["Sharps Container 3 Gal. (10Ea/Bx) ",6]
["Suction Catheter 08 FR 50  ",50]
["Suction Catheter 12 FR 50  ",50]
["Urine Drainage Bags (20ea/bx) ",2]
[" Mask Face HSI Earloop Blue 50/bx 6  ",6]
[" Acohol Prep Pads (200ea/bx) 1  ",1]
["T-Connnector Extension Set 25  ",25]
["Endo-Tracheal Tube 3.0 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 3.0 mm 3 ",3]
["Endo-Tracheal Tube 3.5 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 3.5 mm 3 ",3]
["Endo-Tracheal Tube 4.0 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 4.0 mm 3 ",3]
["Endo-Tracheal Tube 4.5 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 5.0 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 5.0 mm RAE uncuffed 36  ",3]
["Endo-Tracheal Tube 5.5 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 5.5 mm RAE  Cuffed 24",3]
["Endo-Tracheal Tube 6.0 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 6.0 mm RAE  Cuffed 18  ",3]
["Endo-Tracheal Tube 6.5 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 7.0 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 7.0 mm RAE  Cuffed 18  ",3]
["Endo-Tracheal Tube 7.5 mm Cuffed 3  ",3]
["Endo-Tracheal Tube 7.5 mm RAE  Cuffed 12",3]
["Suction Machine Cannister, 1200cc,  ",4]
["Disposable Suction Tubings ",12]
["ECG Monitoring Electrodes  Disposable Infant ",450]
["ECG Monitoring Electrodes  Disposable Adult",120]
["Airway,Oral, Adult 90mm ",5]
["Airway, Oral, Peds 50mm ",4]
["Airway, Oral Small Child 60mm ",5]
["Airway, Oral Small Adult 80mm ",2]
["Nasopharyngeal Airway w/Adj.Flange  12FR 4.0mm",2]
["Nasopharyngeal Airway w/Adj. Flange  14FR 4.7mm",2]
["Nasopharyngeal Airway w/ Adj. Flange 16FR 5.3",2]
["Nasopharyngeal Airway w/Adj.Flange 20FR 6.7mm",2]
["Nebulizer Kit, Pediatric ",2]
["Intubating Stylet 8 FR ",2]
["Intubating Stylet 10 FR ",2]
["Tongue Depressor, Wood, Adult ",150]
["MEDICATIONS"]
["Atropine Sulfate .4mg/ml 1ml ",5]
["Dexamethasone Sodium Phosphate 4mg/ml 5 ml ",10]
["Epinephrine Bristojet  1:10,000,01mg/ml 10ml ",2]
["Ephedrine Sulfate Injection 50 mg/ml  ",10]
["Water for Injection, Sterile 1,000 ml  ",1000]
["Adenosine Injection (Adenocard)  6mg/2ml ",6]
["Amiodarone IV (Cordarone IV)  150mg/3ml ",2]
["Azithromycin (Zithromax) 250 mg  Tablets (30/bt) ",2]
["Bicarbonate Inj. 8.4% Sodium 50ml ",6]
["Cephalexin (Keflex) Capsules (100/bt) ",6]
["Dexamethasone Sodium Phosphate  4mg/mL 5ml ",2]
["Dextrose Injection 50% (0.5n/ml) 25 g  per 50 ml ",1]
["Epinephrine Bristojet  1:10,000,01mg/ml 10ml ",2]
["Furosemide (Lasix) inj 10mg/ml 2ml 2  15ml 2.25% ",10]
["Solu-Medrol 40 mg 1 ml Act-O-Vail ",4]
["Water for Injection, Sterile 1,000 ml  ",1000]
["Foley Catheter 8 FR ","10pcs"]
["Acetaminophen Extra Strength 500  mg ",1]
["Cipro 500 mg Tablets (100/bt) ",20]
["Alcohol Prep Pads ",1]
["Vacutainer Red Tube ",9]
["21 Ga Vacutainer w/ blood collection  et (pre-attached)  ",6]
["Bicarbonate Inj., 8.4% Sodium 50 ml ",2]
["Calcium Chloride Inj. 10% (100mg/ml)  10ml ",2]
["Dextrose Injection 50% (0.5/ml) 50ml ",1]
["Terbutaline (Brethine) Sulfate Inj.  1mg/ml 1ml ",2]
[" Digital pulse oximeter ",1]
["Thermo Scan",1]
["Blood Pressure Set ",1]
["Adult ventilator circuits ",1]
["Pediatric ventilator circuits",1]
[]
["Basic Primary Care"]
["Disinfection set for equipment",2]
["Emergency light",1]
["Examination Couch, standard",1]
["Garbage can (steel) with foot operated lid",6]
["Wheelchair, transport",1]
[]
["Consultation"]
["Patients Clothes, Staff, Small, Blue",3]
["Clothes, Staff, Medium, Blue",6]
["Clothes, Staff, Large, Blue",3]
["Drug dispensary trolley",1]
["Footsteps for examination couch",1]
["Garbage can, steel, with foot operated lid",1]
["Instrument table (mayo stand)",1]
["Ophthalmoscope / otoscope set",2]
["Scales",1]
["Screen, 3 parts, on wheels",1]
["Sphygmomanometer, aneroid with 3 different cuffs",3]
["Stool, adjustable with backrest",1]
[]
["ISOLATION ROOM"]
["Defibrillator, semiautomatic, wall attachment",1]
["ECG machine, 3-6 channel",1]
["Emergency bag, doctor/nurse/paramedic",2]
["Glucometre, electronic, using dry chemicstry technique",1]
["Infusion pump, portable ",1]
["Intubation set / Laryngoscope",2]
["IV stand / Perfusion stand",2]
["Nebulizer ",1]
["Oxygen concentrator",1]
["Oxygen cylinder, portable, complete (1800psi)",5]
["Refrigerator, commercial",1]
["Resuscitator bag with , masks and oral tubes (\"Ambu\")",2]
["Suction pump, electric ",1]
["Suction Unit, manual, portable",1]
["Trolley transport/transfer  ",1]
["X-ray View box",1]
["Crash Cart / Resuscitation trolley",1]
[]
["PHARMACY"]
["Safe, small,  for registered drugs",1]
["Shelving and lockable cupboards",1]
[]
["STERLIZATION"]
["Autoclave, one step, 10-15 l, with baskets",1]
["Sterilization, Hot Air Sterilizer",1]
["Alcohol 70% (5 Liters)",20]
[]
["PERSONAL PROTECTION EQUIPMENT (PPE)"]
["Thermometer",21]
["Face Masks surgical (box 50)",7]
["Face Mask N95",7]
["Face Mask FFP3",7]
["Gloves Disposable Ruber (box of 100)",7]
["Gloves Sterile Ruber ",7]
["Gowns Disposable plastic (box of 50)",7]
["Cap Disposable (box of 10)",7]
["Shoe Cover disposable (box of 10)",7]
["Gogles protective",7]
["Overalls Disposable",7]
["Biohazard Bag",50]
["Apron disposable plastic",10]
["Transportation cost (if applicable)"]
["TOTAL PRICE"]
[]
["Name of the bidder (Company/firm) ----------------------------------------------"]
[]
["Name and signature of the supplier’s authorized person: ------------------------------------"]
[]
["Designation (Title) -----------------------------------------------------"]
[]
["Date: ---------------------------------"]
[]
["Contact person: ---------------------------------------------"]
[]
[]
["Email address: --------------------------------------------"]
[]
["SIGNATURE /STAMP ------------------------------------------"]