Please return to: Support Services Team, MND Association

Email:

Tel: 01604 611802

Fax: 01604 638289

Office use:

Date received:

Date acknowledged:

Decision & date:

Date actioned:

APPLICATION FORM - REQUEST FOR EQUIPMENT LOAN

The MND Association cannot use its resources to replace statutory responsibilities. In completing this application form, health and social care professionals should include supporting documentation demonstrating efforts made to secure statutory provision. In signing this application form the professional confirms every effort has been made to seek statutory and other appropriate resources.

Please email completed form to We will not process incomplete forms. Referring professionals must ensure applications are fully completed and returned in a timely manner. Please include ethnicity according to Department of Health coding.

1. DETAILS OF PERSON WITH MND

Full name of person with MND consenting to this request
Mr/Mrs/Ms/Miss/Dr/Other......
First Name: Surname: / Gender:
Male:
Female:
Ethnicity code:
Date of diagnosis: / Place of diagnosis:
(i.e. name of hospital/care centre)
Address
Postcode / Date of birth:
Contact details (if different):
Name:
Tel./Email
Mobile number/E-mail:
Telephone

2. DETAILS OF PROFESSIONALS

Name of requesting professional / Job title
Address
Postcode / Contact name and telephone/e-mail of a colleague who can be contacted if you are unavailable
E-mail
Telephone
Normal working hours when you can be contacted:
GP’s name and address:

3. DETAILS OF EQUIPMENT LOAN REQUEST

Please note: The provision of suction units is a statutory requirement. While we are continuing to loan suction units, we are now requesting that statutory services contribute £50 towards the transport, maintenance and cleaning costs of each unit requested. Please tell us the name of the person we need to invoice for the £50 payment, or send us a purchase order. This request should not delay delivery. We will continue to review the provision of suction units, along with other items that are part of our current core loan items.

Items requested with details of specification, for riser recliners, please complete dimension sheet.
Delivery address for equipment:
Postcode: / Telephone:
Any other relevant information i.e. access
For Suction units: Please tell us the name of the person we need to invoice for the £50 payment

4. FUNDING BY STATUTORY AGENCIES OR OTHERS

Detail what attempts have been made to secure the equipment/funding from the statutory services
Reason why this need cannot be met by statutory services
If the equipment or service is available from statutory services but there is a waiting list please state the date the equipment or service is likely to be available: / Date:
Details of other charities or organisations that have been approached for funding

5. ANY OTHER INFORMATION RELEVANT TO THE APPLICATION

6. STATEMENT BY THE REFERRING PROFESSIONAL

If this application is approved, I understand that, unless otherwise agreed with the support services team:
·  Where appropriate, it is my responsibility to continue to pursue funding from statutory services
·  It is my responsibility to monitor and assess the ongoing needs of the person with MND in relation to this application.
·  It is my responsibility to notify the relevant statutory service that the MND Association has provided equipment loan services to a person with MND
·  Should I leave my current post, I will notify the MND Association of the name of the professional who has taken on the responsibility for ongoing communication and liaison with the MND Association
·  I will monitor suitability, provide any necessary instruction, and will notify you when equipment is no longer needed.
Signed: / Date:


CHAIR DIMENSIONS SHEET

Dimensions Required:

As we have various sizes of chairs please complete the details below and return to us as soon as possible to enable us to ascertain which chair to supply. Please state actual dimensions and select preferred chair options.

Approximate Height: Approximate Weight:

Dimensions in inches:

1. Floor to seat height:

The correct seat height can be calculated by measuring the distance from the floor to the

crease at the back of the knees. When seated, the hips and knees should be at right

angles whilst the person’s feet are flat on the floor. (Remember to wear usual footwear)

Select option: 16” 18” 20”

2. Seat front to back:

To calculate the correct seat depth, measure the distance from the back of the hips, along

the thighs to approximately 1½” behind the back of the knees. When seated you should be

able to place two fingers between the edge of the seat and the back of the knees.

Select option: 18” 20”

3. Seat to top of head:

From rear of seat level to top of head to protect head in chair recline.

Select option: 30” 33”

4. Seat width inside arms:

The correct seat width should be the width of the person’s hips plus a clenched fist on the either side (approximately 3”)

Select option: 18” 20”

Convertor:

Inches / 16 / 18 / 20 / 30 / 33
Millimetres (approx) / 400 / 450 / 500 / 760 / 840

Motor Options:

Single Motor Tilt-in-space 2 way: Dual Motor 4th position:

Any other comments

The request will be placed on our waiting list and processed as soon as possible. If there is likely to be a problem (for instance - unusual requirements) we will contact you by phone to discuss. We cannot guarantee to match the dimensions exactly but will supply a chair as close to those given as possible.

Please also complete a loan request form and return both sheets to:

Support Services Team

Motor Neurone Disease Association

PO Box 246

Northampton, NN1 2PR

Tel no: 01604 611802

Fax no: 01604 638289

Email:

Motor Neurone Disease Association, 10-15 Notre Dame Mews, Northampton, NN1 2BG Registered Charity no: 294354