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WEST SUFFOLK HOSPITALS NHS TRUST CONDEMNING AND DISPOSAL FORM FOR ELECTROMEDICAL EQUIPMENT. LOCATED AT :
UNIT...................................................................................................................................... DEPARTMENT...................................................................................................................... EQUIPMENT NAME............................................................................................................. MODEL................................................................................................................................. MANUFACTURER................................................................................................................ HOSPITAL REGISTRATION NUMBER............................................................................... SERIAL NUMBER................................................................................................................ DATE LOGGED ONTO REGISTER..................................................................................... PART 1. To be completed by Clinical Manager / Head of Department: I certify the equipment listed above has been removed from use in this department for the following reason(s). Please tick relevant items. (a) Obsolete [......] (b) Clinically unsafe [......] (c) No longer required [......] and is therefore no longer suitable for use in this department. The equipment will / will not be replaced by........................................................................................................................................... requested on requisition No..................................... dated........................................ Signed............................................................. Designation............................................................. PART 2. To be completed by the EBME Manager / Director of Facilities : I certify the above equipment is (a) Serviceable [......] (b) Electrically unsafe [ .....] (c) Mechanically unsafe [......] (d) Beyond economic repair [......] (e) Other [......] State............................................................................. I recommend that the equipment is disposed of : (a) By return to Supplies for disposal [.......] (b) As scrap [.......] The equipment record will be removed from the computerised record system and inventory list and all maintenance schedules and contracts cancelled. Signed...................................................... Designation................................................................... Date.......................................................... Please photocopy on completion and return original to EBME Department. Remove from HECS [ ]
WEST SUFFOLK HOSPITALS NHS TRUST INDEMNITY
I (name) of . .
..(address & telephone number) Hereby indemnify West Suffolk Hospitals NHS Trust, the Secretary of State for Social Services and the Crown against all costs, charges, expenses, actions, claims and demands in respect of any damage or injury (including injury resulting in death) to any person or property ensuing by taking on loan Nebuliser Compressor number WHSA .. I have checked Nebuliser Compressor number WHSA .., the property of the West Suffolk Hospital, is in satisfactory condition. I shall be responsible for and will make good or pay compensation for any such damage or injury to the satisfaction of the Secretary of State for Social Services through his agent, the West Suffolk Hospitals NHS Trust I confirm that I have received instruction in the correct use of Nebuliser Compressor number WHSA ..
Signed . Date Witnessed for West Suffolk Hospitals NHS Trust Signed . Date Position NATIONAL HEALTH SERVICE FORM OF INDEMNITY - D FREE ISSUES FOR TRIAL OR TESTING WEST SUFFOLK HOSPITALS NHS TRUST AN AGREEMENT made the _____________________day of_________________________ 200_ BETWEEN _________________________________________________________ (theWest Suffolk Hospitals NHS Trust) And ________________________________________________________________ (the Supplier). WHEREAS (1) The Supplier is the owner of the goods described in the Schedule (the Goods). (2) The Supplier wishes to give the Goods to theWest Suffolk Hospitals NHS Trust so that theWest Suffolk Hospitals NHS Trust may use the Goods for the benefit of the Supplier for the purpose of evaluation, testing, research, design investigation or trial demonstration.
IT IS HEREBY AGREED that the Supplier shall transfer the Goods free of charge to theWest Suffolk Hospitals NHS Trust on the terms set out below. 1 . The transfer of the Goods shall be deemed to be a contract for the transfer of goods as defined by Section 1 (1) of the Supply of Goods and Services Act 1982. 2. The Supplier agrees that this transaction and the transfer of goods effected by it shall be subject to the current National Health Service Conditions of Contract for the Purchase of Goods (except Conditions 9 11 12 14 17 20 21). SIGNED on behalf of theWest Suffolk Hospitals NHS Trust ________________________________________________ SIGNED on behalf of the Supplier ________________________________________________
October 1996 THE SCHEDULE
Model/Mark No: ________________________________________________________ Serial No: ____________________________________________ (if applicable) Value: ________________________________________________________ Description: ________________________________________________________ MIA No: ____________________________________________ (if applicable) The above goods will only be used in the premises or location identified in '3' below and will NOT be used elsewhere or for any other purpose than that specified in '4' below without the written consent of the supplier. 2. Date of Transfer of Goods __________________________ day of __________________200_. 3. The Premises / Location 4. The Purpose of the Free Issue
5. Health and Safety BY signing this schedule both parties acknowledge their responsibilities under the Health and Safety at Work Act and COSHH 1994. 6. Confidentiality By signing this schedule both parties acknowledge the confidentiality requirements of this agreement. SIGNED on behalf of theWest Suffolk Hospitals NHS Trust __________________________________________________ SIGNED on behalf of the Supplier __________________________________________________
Request For Product Information FORM PPQ(A)
PRE-PURCHASE QUESTIONNAIRE FORM PPQ - Issue 3 February 1999 Produced by: NHS Supplies, Scottish Healthcare Supplies, Northern Ireland CSA Regional Supplies Service and Welsh Health Supplies in conjunction with the Association of British Healthcare Industries. This form is intended to supply prospective purchasers with information about equipment being considered for purchase. It is intended principally for pre-purchase information on electrical medical, dental, ophthalmic and laboratory equipment. The form may also be used for other products, including non-electrical items, and to give information prior to equipment being supplied on loan, in which case not all the questions will be relevant. Please ensure all relevant questions are answered.
CE MARKING 1 a) Does the product carry the CE marking? YES NO b) If YES, which EC Directive(s): i) Active lmplantable Medical Devices Directive (90/385/EEC) YES ii) Medical Devices Directive (93/42/EEC) YES If YES, state classification of device (93/42/EEC Annex IX) Identification No. of Notified Body, if applicable: iii) EMC Directive (89/336/EEC) YES iv) Low Voltage Directive (73/23/EEC) YES v) Other (please specify) YES If YES to i) or ii) above, go to question 5 2. a) Is the product a "custom-made" device? YES NO b) Or a "device intended for clinical investigations"? YES NO If YES, does it comply with the UK Medical Devices Regulations? YES NO QUALITY ASSURANCE 3. Is the manufacturer currently registered to any other specific quality system YES NO standard for this product ? If YES, please state the standard: SAFETY STANDARDS 4, For devices not CE marked to 1 b) i) or ii) above, with which safety standard(s) does the equipment comply?
SERVICE / SPARES / INSTALLATION 5. Is service/repair information/manual provided? YES NO If YES, please state current price: and indicate contents below:
6. a) In addition to the service/repair information/manual, will training be Required before the purchaser's technical personnel can provide: (Please answer YES, NO or NIA)
b) For those indicated by YES above, is the supplier able to provide training for the purchaser's technical personnel? If YES, will this be free of charge Or chargeable? If NO, please indicate if details of an organisation which is able YES NO provide this training are available on request:
7.a) Is the supplier able to provide an 'as required' repair/maintenance service in the UK? YES NO b) Is the supplier able to provide a contract repair/maintenance service? YES NO If YES, please confirm that details of repair/maintenance contracts are YES NO provided on a separate sheet: c) i) Will repairs normally be performed on the purchaser's site? YES NO ii) If repairs are performed off-site, where will these be carried out? Company: Location 8 Is the supplier's maintenance organisation currently registered to a quality system standard YES NO If YES, please state the standard:
9. Please indicate when the item was first put on the market:
is the supply of spare parts guaranteed? 11. Please indicate if spare parts will be made available to the purchaser: YES NO 12. Is installation necessary? YES NO If YES, please confirm that details of all services required are given on a separate sheet: YES DECONTAMINATION 13. Does decontamination require the use of specific equipment YES NO If YES, please state equipment type and parameters of operation (e.g. temperature, pressure, etc): 1 WARRANTY 14. Please confirm that a copy of the warranty is provided on a separate sheet YES
YEAR 2000 15 Is the equipment date format and Year 2000 compliant in accordance with the current BSI definition YES NO
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