Medical Equipment Donations Assessment and Advisory Service (MEDAAS)

Offer for a Donation

A separate request form needs to be submitted for each type of equipment/material.

How many units ?  ……….    Where located ? …….

Why is/are  it/they being donated ? ….

Have the formalities required by the donating institution – release, disposal etc – been completed ?  Y/N

The offered item

        -  name of item  and function (if not obvious) ………………………………………………………

        -  full identification  (model, mark, number  etc   etc   …………………………………………

        -  manufacturer    …………………………………………………………………………………..

        -  date of manufacture  …………….        still in production?  Y/N     

        -  are spare parts  available ?   Y/N       Supplier ? ……………. ……………..  

        -  are maintenance, service, and simple repairs able to be done by a suitably trained user    

           and/or  local equipment technician/engineer (as opposed to service technicians/engineers

           from the manufacturer ?)      Y/N

-  are major repairs able to be done on site (as opposed to need to transport elsewhere)?   Y/N

-  is the user manual included ?   Y/N        language  ………………

-  is the service manual included ?   Y/N      language  ………………

-  recommended service intervals ?  ………………………………………..

What infrastructure and resources are necessary for function?

        -  water ?  Y/N   Details ……………………………………………..

        -  electric power ?  Y/N    Details:   voltage ……  (V)    frequency …….. (Hz)   

                 power consumption  …….(watts)              

        -   internal battery?  Y/N       battery type? ……..     battery life?.....           

        -  compressed gas(es)?   Y/N   Details …………………………………………………………………….

        -  gas fittings type?………………………………………………………………………………..

        -  specific building structure? Y/N    Details …………………………………………………………

        -  human resources  -  any special skills, training etc ?  …………………………………………….

Present condition    (separate info for each (numbered) unit  offered, to be provided)

-  in working order NOW?  Y/N                                            

-  date of last service ?…………    

-  service by whom ?…………….

-  hours of use since last service ?……….

-  total hours of use ? ………… 

ANY OTHER RELEVANT INFORMATION?

Information provided by:

 Name

Position

Organisation

Contact details

P Coyle