ELMS2 PIN REQUEST FORM

Units 4-7, Graylaw Trading Estate, Wareing Road
Aintree, Liverpool
L9 7AU

0151-295-9800

N.B your form will be returned to you and delayed if incorrect or incomplete.

Forms to be submitted on email from the authorising signature and forwarded to the community equipment inbox for processing.

User Details

First name: / Base:
Surname: / Team:
Job Title: / Band:

Contact Details

Telephone Number:
Mobile Number: / Email:

User's Declaration of Ordering Equipment

I confirm and understand that by completing the equipment order referral form, I am accepting that I am competent to prescribe / issue this equipment and responsible for assessing the safe and correct use at the time of issue. I have a clear understanding of my responsibility and accountability for prescribing community equipment and medical devices. I have completed the e-reader Community Equipment Service Resource Guide.

Name: / Signature:
Surname: / Date:

Manager Authorisation

LCH staff - Has staff member completed the e-reader Community Equipment Resource Guide?

YES

NO

Please note this is a pre-requisite of obtaining a PIN number to demonstrate they have full knowledge of processes and procedures for prescribing equipment.

External Referrers – It is an essential requirement that the Resource Guide is read by the practitioner prior to being given authorisation by the line manager to order equipment. Your own organisation will have made provision for you to access this guide.

First name: / Base:
Surname: / Team:
Job Title: / Band:
Signature: / Date:

Contact Details

Telephone Number: / Email:

Code of Conduct

You have been provided with access to order equipment from Liverpool Community Equipment Stores. The following Code of Conduct must be adhered to and observed at all times:

·  Do not distribute your pin to anyone else – this is personal to you and should not be shared amongst colleagues.

·  If you move employer and/or base you must let the service know so they can update your records accordingly on ELMs.

The Service has the right to monitor user access and activity. Pins that are shared will be revoked. Pins that are inactive for 12 months will also be withdrawn.