Medical Equipment Donations Assessment and Advisory Service (MEDAAS)

Request for a Donation

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

Identification of  item

General:   eg  anaesthetic vaporiser,  Xray machine   etc    …………………………………………….

Specific:   eg  particular type, manufacturer, brand, etc   ………………………………………………..

Infrastructure, resources reliably available on site

  - electric power?  Y/N          voltage ……..   frequency…….

  - water?   Y/N      piped   Y/N

  - oxygen?   Y/N      compressed   Y/N   cylinder  [  ]   pipeline   [  ]    concentrator   [  ]

  - other gases ?    ….. ………………………………..

  - gas fittings  type?……………………….

  - suitable housing?    Y/N 

  - technical/engineering support   (maintenance, servicing, repairs)?   Y/N   

Other information

 -        is this item still being manufactured ?  Y/N

-        are spares available?   Y/N

-        date last manufactured ?  ………

-        are the clinical users familiar with this item or this category of item ?  Y/N

-        is it compatible with equipment in use on site ?   Y/N

-        why is this request being made ? …………………………………………………………………

ANY OTHER RELEVANT INFORMATION ?

 Information provided by:

Name

Position

Organisation

Contact details

P Coyle