CIL

Administrative Memorandum No. 10-10

July 1995

Revised July 1998, March 2001

General Office Section

Adaptive Equipment Donation & Loan Policy

Purpose:To inform the CIL staff about the adaptive equipment for loan to consumers that may find them in need of it. All adaptive equipment is donated to the CIL.

General

Information:The loan of the adaptive equipment is based on the consumer’s need and willingness to complete a "Consumer Receive and Release of Liability Form" (See Attachment A). The forms are kept in the Administrative files in the supply room. The file is marked "Equipment Loan Agreement".

Procedure:1.The Administrative Assistant keeps an on going list of all available donated adaptive equipment. (See Attachment B). When the CIL Staff receives a donation or loans out any adaptive equipment make sure it is documented properly.

  1. When receiving donated adaptive equipment Staff need to request the following information:
  1. The donors name, address list of all adaptive equipment donated, and any serial numbers. A statement to the condition of the equipment should also be noted. (See Attachment B)

3.When a consumer comes in and makes a requests for adaptive equipment please be sure that the CIL has the following information:

  1. The person is a consumer of the CIL.
  1. The Service Provider and the Consumer need to make sure the Release of Liability form (See Attachment C) is filled out and then go over the form with the consumer to be sure they understand their obligations and financial responsibility. Then have them sign and date the form (if possible). The completed form then needs to be routed to the Administrative Assistant.

NOTE:The Staff member loaning the adaptive equipment should fill in the description of the adaptive equipment including its condition. If there is something wrong with the adaptive equipment, it should be documented in the area marked “Office Use only” at the bottom of the form.

NOTE:After the consumer signs the release form they become financially responsible for the cost of repairs, maintenance, or replacement of parts while the equipment is in their care.

  1. When completing the form, please include the following information:
  1. Name, address of the Consumer its going to, what condition the adaptive equipment is in, and a complete description of the equipment including any serial numbers.

______

Executive Director

Attachment A

CIL

IN-KIND ADAPTIVE EQUIPMENT LIST

Staff / Serial # / Equipment Description / Date in / Date Out / Location

Note: Under Staff list Initials, and under Location list Center as CIL or the consumer name.

ATTACHMENT B

CIL

DONATION OF EQUIPMENT

I, ______here by donate said equipment and release all liability there of the CIL.

Name: ______

Address: ______

City: ______State: ______Zip: ______

Phone: (______)______

Equipment Description: ______

______

Serial Number: ______

Office use only

Equipment condition: (Please Circle One)

PoorFairGoodVery GoodExcellent

Anything noticeably wrong with the equipment: ______

______

______

Received by: ______

Received date: ______

ATTACHMENT C

CIL

CONSUMER RECEIVING AND RELEASE OF LIABILITY FORM

I, ______am the undersigned, of legal age, do receive any and all Medical Equipment and or Supplies with the full understanding that the Medical Equipment & or Supplies are as is, regardless of their condition, on the day of receivership. I further understand that the CIL will not be held responsible for the condition, upkeep, or repair of said Medical Equipment and/or Supplies and by my signature state that I accept full responsibility for said Medical Equipment and/or Supplies, described below.

Details: ______

______

______

Signature of persons accepting Medical Equipment, Supplies and accepting full responsibility for items described above.

Signature: ______Date: ______

Service Provider: ______Date: ______

Witness By: ______Date: ______