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SFHM-PUR-FRM-005 Capital Equipment Request Form

This document is a capital equipment request form from the Security Forces Hospital Program in Makkah, Saudi Arabia. It requests approval to purchase a new piece of medical equipment and provides details on the equipment, its purpose, installation requirements, and reviews from relevant departments. Specifically, it seeks a replacement for an existing piece of equipment to improve patient care. Biomedical engineering, IT, and materials planning must review the request to ensure the equipment's installation and use meet technical and supply requirements. Final approval is needed from the director of medical affairs and hospital program.

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Tarek Ibrahim
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109 views3 pages

SFHM-PUR-FRM-005 Capital Equipment Request Form

This document is a capital equipment request form from the Security Forces Hospital Program in Makkah, Saudi Arabia. It requests approval to purchase a new piece of medical equipment and provides details on the equipment, its purpose, installation requirements, and reviews from relevant departments. Specifically, it seeks a replacement for an existing piece of equipment to improve patient care. Biomedical engineering, IT, and materials planning must review the request to ensure the equipment's installation and use meet technical and supply requirements. Final approval is needed from the director of medical affairs and hospital program.

Uploaded by

Tarek Ibrahim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Kingdom of Saudi Arabia

CAPITAL EQUIPMENT REQUEST FORM Ministry of Interior


General Administration for Medical Service
Security Forces Hospital Program - Makkah

Department:
Date Submitted:
Prepared by:

 New  Replacement  Expansion  Upgrade


Select one:
 Minor Equipment < SR1000

1. Equipment Description
Name of Equipment:
Describe Function:

2. Building/Room where equipment will be located. (_______________________________________)

3. Please list all available manufacturers beginning with your preferred manufacturer first.
Manufacturer Model Justification

4. Items to be replaced.
Asset Number: Other Identification:

Serial Number: Name of Equipment:

Manufacturer Name: Model Number:

5. Reason for replacement.


Maintenance costs too high.  Yes  No
Parts no longer available.  Yes  No
Equipment unreliable and past useful life.  Yes  No
Other, explain:  Yes  No

6. Site preparation requirements.

CODE: SFHM-PUR-FRM-005 ISSUE DATE: 04.01.2015 / ISSUE No.: 1 / REVISION No.: 0 PAGE 1 OF 3
Kingdom of Saudi Arabia
CAPITAL EQUIPMENT REQUEST FORM Ministry of Interior
General Administration for Medical Service
Security Forces Hospital Program - Makkah

Identify if Equipment will require:

Standard electrical and / or emergency power.  Yes  No


Building modifications to install or use.  Yes  No
Water, sewer/drainage, or steam connections.  Yes  No
Compressed gas, air, oxygen, or vacuum utility connections.  Yes  No
Radiation, laser, radio waves, or radioactive components permits or review  Yes  No
Special structural support due to weight or size  Yes  No
Modifications to heating, ventilation, or air conditioning  Yes  No
Installation by:  In-House  Vendor
Additional construction or renovation of current space  Yes  No
If yes please describe:

Comment :

7. List external approvals or registrations required for this acquisition:


Operating Certificates  Yes  No
Regulatory approvals (specify)  Yes  No
Laser, nuclear or x-ray registrations  Yes  No
Other (explain):

8. Why is the equipment needed? (New technology, replacement, increased volumes etc.):
__________________________________________________________________________________
__________________________________________________________________________________

9. Explain any efficiency gained with this piece of equipment. (e.g. staff will be more efficient,
procedure time will decrease, etc.):
__________________________________________________________________________________
__________________________________________________________________________________

NAME POSITION SIGNATURE/DATE

REVIEWED BY:
SIGNATURE/DATE

APPROVED BY: Director of Medical Affairs


SIGNATURE/DATE

Director of Hospital
APPROVED BY:
Program SIGNATURE/DATE

DEPARTMENT REVIEWS:

CODE: SFHM-PUR-FRM-005 ISSUE DATE: 04.01.2015 / ISSUE No.: 1 / REVISION No.: 0 PAGE 2 OF 3
Kingdom of Saudi Arabia
CAPITAL EQUIPMENT REQUEST FORM Ministry of Interior
General Administration for Medical Service
Security Forces Hospital Program - Makkah

(This section will be completed by the Capital Equipment Committee, do not forward your requests to
these support Departments)

Biomedical
Engineering IT&C Material Planning
Engineering
1. Do you expect 1. Is site modification 2. Will Out-Access 1. Are supplies
support problems? required? Connections be needed to
needed? operate?
 Yes  No  Yes  No  Yes  No  Yes  No
2. Maintenance will be 2. Maintenance will be 2 Are interfaces to 3. Will equipment
provided: provided: other systems duplicate or
needed? eliminate current
 In-house supplies?
 Service Contract  In-house  Other  Yes  No  Yes  No
If question 1 is Yes, If Yes or Other, explain: If question 2 is yes, Explain:
explain: explain:

3. Other 3. Other considerations 3. Other considerations 3. Other considerations


considerations: i.e.,
Risk Rank, Life
Expectancy
Improved patient flow.

4. Cost of following (if 4. Cost of following (if 4. Cost of following (if


required): required): required):
Annual Service Annual Service Annual Service
Contract Contract Contract
Training Training Training
Test/Support Test/Support Test/Support
Equip Equip Equip

NAME POSITION SIGNATURE/DATE

REVIEWED BY: Biomedical Engineer SIGNATURE/DATE


Manager of Material
REVIEWED BY:
Planning SIGNATURE/DATE
Director IT and
REVIEWED BY:
Communication SIGNATURE/DATE

REVIEWED BY: Director of Engineering


SIGNATURE/DATE

CODE: SFHM-PUR-FRM-005 ISSUE DATE: 04.01.2015 / ISSUE No.: 1 / REVISION No.: 0 PAGE 3 OF 3

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