D.4 CM90-15 TESTING EVALUATING OR DEMONSTRATING NEW EQUIPMENT OR SUPPLIES.pdf

CENTER MEMORANDUM NO. 90-15

ATTACHMENT A

Date:

From:

Subj: Request for Demonstration (up to 48 hours)

To: Logistics Manager (90)

1. Request for demonstration of item will be addressed to Logistics Manager (90), and include the following information:

a. Name or description of item.

b. Name and address of vendor desiring to give the demonstration.

c. Suggested time and date of demonstration/time and date of removal from premises.

d. Names of other services that may be interested in the product.

e. Safety Inspection of electrical parts and work orders submitted to Engineering.

f. Vendor will complete Attachment C “Vendor ePHI Statement of Condition” and a copy will be attached for future reference.

g. Signature of Department/Service Manager.

Department/Service Manager Signature

h. Concurrence block under signature.

APPROVED/DISAPPROVED

Logistics Manager (90) DATE

ATTACHMENT B

Date:

From:

Subj: Request to Test/Evaluate New Equipment of Supplies

To: Logistics Manager (90)

1. Request to test or evaluate any item will be addressed to Logistics Manager (90), and include the following information:

a. Name of item part or model number, manufacturer’s descriptive literature or drawings, and suggested price.

b. Whether the item is patented or proprietary, names of manufacturers, names of similar products and specific reasons for recommending evaluation of the particular product.

c. Whether the item is to be loaned, donated or purchased.

d. The station(s) and services(s) to conduct the test(s).

e. Purpose of testing – advantages that will result if test is successful, stated in tangible benefits when possible.

f. An outline of test procedure or protocol, including controls to be maintained and comparisons to be made with existing items and/or procedures.

g. Length of test – minimum necessary (generally not more than 90 days) to accomplish purpose.

h. Vendor will complete Attachment C “Vendor ePHI Statement of Condition” and a copy will be attached for future reference.

i. Concurrence block under signature.

APPROVED/DISAPPROVED

Logistics Manager (90) DATE

ATTACHMENT C

Vendor ePHI Statement of Condition

I, _________________________________________________, an agent authorized to represent

_____________________________________________, declare that I will not use any patient information during the demonstration of this medical device. If any patient information is entered into my system I will forfeit my hard drive at no cost to the WNY VA Healthcare System.

DEVICE MANUFACTURER MODEL SERIAL #

Signature:____________________________________ Date:________________

We thank you for your compliance and respect of our Veterans’ personal information

Logistics Manager (90) DATE