Date«
Requestor«
Phone Number«
Email«
Fax
Department«
CLINICAL CONTACT FOR QUESTIONS
Name«
Phone Number«
Beeper Number
Email«
Fax
CORPORATION CODE«
-- Select from the following --
JHH 01
JHH OPC 01
JHMSC 23
JHBMC 30
Grants Program 31
JHBCC 35
JHHS 60
Other
Corporation Code Other
If code is not listed above, please provide it
PRODUCT INFORMATION: Please forward manufacturer's specifications, literature, pricing and vendor's business card
Product Name«
Product Description (Include unit of measure)«
Manufacturer«
Mfr Catalog #«
"M" ACCOUNT STATUS DETERMINATION
Is this item for home care use?«
[
Yes
]
[
No
]
Will this item be used for patient care?«
[
Yes
]
[
No
]
Is this item disposable (for single patient use)?«
[
Yes
]
[
No
]
Is this item a medically necessary part of the patient's current treatment?«
[
Yes
]
[
No
]
Comments
QUESTIONS
Does/could this product replace a similar product currently in use?«
[
Yes
]
[
No
]
If so, please describe
Item #, Mfr Catalog #
Describe how the item will improve clinical care/outcomes if purchased.
Advantages
Disadvantages
What is the approximate annual *each* usage?
Is item a patient/staff safety improvment?«
[
Yes
]
[
No
]
Describe
Will item affect other departments/affiliates?«
[
Yes
]
[
No
]
If yes, list
If item will affect other departments, have you communicated product information to them?
[
Yes
]
[
No
]
If yes, list
Will item require approval from another committee or department? (eg: Infection control, CES, Medical Staff, Nursing, Radiology, etc.)?«
[
Yes
]
[
No
]
If yes, list
Will new/additional devices be needed to use this product? (ie: disposables, reusables)«
[
Yes
]
[
No
]
If yes, list additional equipment
Is an evaluation of the item necessary?«
[
Yes
]
[
No
]
If yes, list locations that may participate
Has an evaluation tool, including outcomes and evaluation measures, been developed?
[
Yes
]
[
No
]
If yes, provide a contact name with phone number, pager or email
Will this item require a change in policy/procedure/protocol?«
[
Yes
]
[
No
]
If yes, list policy/procedure/protocol affected
Would item require education for clinical staff?«
[
Yes
]
[
No
]
If yes, who will carry out this requirement?
Will this item have an affect on environmental resources? (eg: cleaning/disposal, storage)«
[
Yes
]
[
No
]
If yes, resources affected
Is this item FDA approved?
[
Yes
]
[
No
]
Comments regarding FDA approval
Do you have any interest in the selection of this item that may be deemed a conflict of interest?«
[
Yes
]
[
No
]
If yes, disclose the relationship you have with the vendor
Is there a cost-containment potential with the purchase of this item?«
[
Yes
]
[
No
]
Describe
