Appendix 1; New Product Request Form
Appendix 1; New Product Request Form
Approval Form for the Introduction of New Medical or Surgical Product
This form needs to be completed before any new products can be introduced into the hospital and needs to be signed off by the UL Hospitals Medical/Surgical Consumables Procurement Committee for Approval
Please provide detail in the Box Provides 1 Description of Consumables Required
2 Approx cost of Purchase including vat,installation,training etc
3 Quantity
4 Proposed Supplier
5 Model Ref/Part no if available
6 Source of Fundings
a. Revenue Budget,
b. Capital
c. Comfort
d. Other
7 Is the item requested
.
a. new product
b. replacement product
c. substitute/alternative
8 Please give reason for the request
.
9 Has this item been purchased before ?y/n 10 Has item been evaluated
11 What was practice previous to this .
12 If replacement what is new product replacing
13 Type of purchase is it a.once off b.reoccurring
14 If reoccurring what is the estimated usage/frequency of order a.weekly b.monthly c.less frequent
Title; New Product Request Form (SOP; Standardisation of Medical & Surgical Products; Appendix 1)
1
Date; May 2013
Edition; 1
Pages; 2
Appendix 1; New Product Request Form
15 If reoccurring order should item be included as standard on your requisition form
16 Are the requested goods/services from the stated supplier the only one who can satisify your requirements
17 If yes please advise what are the unique features of the suppliers product
18 Has the products/services been evaluated by the Hygiene Team
19 Where will the product be stored and is there sufficient space
20 Has all stock re the old consumable been used up? If no what is the valuation of stock remaining
21 Any other relevant information .
Department Name: ___________________________ Phone No: ____________
Requested By____________________________
Date: _________________________
UNO Signature: _____________________________ Date _________________
Approved By Sub Procurement Group: Name: __________________________________ Date_________________
Name:___________________________________ Date_________________ Please email form to Mr Hugh Brady, Chairperson; and Deirdre McNamara, Secretary; UL Hospitals Consumables Committee.
Title; New Product Request Form (SOP; Standardisation of Medical & Surgical Products; Appendix 1)
2
Date; May 2013
Edition; 1
Pages; 2
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