Wallingford Community Hospital League of Friends - Registered Charity No.1022280
For request to grant fund equipment, services and projects that benefit the patients staff and visitors of Wallingford Community Hospital a charity
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Requests to be submitted to the League of Friends at least 2 weeks before the monthly committee meeting, so details can be sent on to committee members. Meetings are at 6pm in the hospital every third Thursday (except August and December) and we might well invite you to come and explain the request further. Please confirm you have read this and agree to the process. *
Required
Which department is the request for? *
Your answer
Details of equipment or service requested: *
Your answer
Is the proposed provider/supplier of the equipment on the Trusts procurement list? *
Has the Trust signed off any infection control requirements for the equipment? *
Has the Trust signed off any health and safety requirements for the equipment, including fire safety if appropriate? *
Tell us why this equipment, service or project will make a difference to patients, staff or visitors. Include evidence of where it's been used elsewhere or any research that demonstrates it's effectiveness. *
Your answer
Has a request for this been made to the NHS (OH/OUH)? *
Please provide details of why the funding request was declined or not made. *
Your answer
Total cost including VAT; *
Your answer
Name of person responsible for making the request *
Your answer
Contact details of the person making the request. *
Your answer
Do you confirm the Trust will hold liability over the equipment's performance and any health and safety issue related to its use, repair and maintenance? *
We will contact you to notify if the request has been approved. Please follow up agreed requests promptly, or tell us if you no longer need or want the order. If equipment is to be ordered by the Trust, do NOT submit any order UNTIL instructed by the committee. If the equipment is to be ordered by the League of Friends the Treasurer will be in contact to agree details. *
If you have any questions or information to add please add it below.
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