Kingdom of Saudi Arabia

CAPITAL EQUIPMENT REQUEST FORM Ministry of Interior

General Administration for Medical Service
Security Forces Hospital Program - Makkah

Department:
Date Submitted:
Prepared by:

 New  Replacement  Expansion  Upgrade

Select one:
 Minor Equipment < SR1000

1. Equipment Description
Name of Equipment:
Describe Function:

2. Building/Room where equipment will be located. (_______________________________________)

3. Please list all available manufacturers beginning with your preferred manufacturer first.
Manufacturer Model Justification

4. Items to be replaced.
Asset Number: Other Identification:

Serial Number: Name of Equipment:

Manufacturer Name: Model Number:

5. Reason for replacement.

Maintenance costs too high.  Yes  No
Parts no longer available.  Yes  No
Equipment unreliable and past useful life.  Yes  No
Other, explain:  Yes  No

6. Site preparation requirements.

CODE: SFHM-PUR-FRM-005 ISSUE DATE: 04.01.2015 / ISSUE No.: 1 / REVISION No.: 0 PAGE 1 OF 3
 Kingdom of Saudi Arabia
CAPITAL EQUIPMENT REQUEST FORM Ministry of Interior
General Administration for Medical Service
Security Forces Hospital Program - Makkah

Identify if Equipment will require:

Standard electrical and / or emergency power.  Yes  No

Building modifications to install or use.  Yes  No
Water, sewer/drainage, or steam connections.  Yes  No
Compressed gas, air, oxygen, or vacuum utility connections.  Yes  No
Radiation, laser, radio waves, or radioactive components permits or review  Yes  No
Special structural support due to weight or size  Yes  No
Modifications to heating, ventilation, or air conditioning  Yes  No
Installation by:  In-House  Vendor
Additional construction or renovation of current space  Yes  No
If yes please describe:

Comment :

7. List external approvals or registrations required for this acquisition:

Operating Certificates  Yes  No
Regulatory approvals (specify)  Yes  No
Laser, nuclear or x-ray registrations  Yes  No
Other (explain):

8. Why is the equipment needed? (New technology, replacement, increased volumes etc.):
__________________________________________________________________________________
__________________________________________________________________________________

9. Explain any efficiency gained with this piece of equipment. (e.g. staff will be more efficient,
procedure time will decrease, etc.):
__________________________________________________________________________________
__________________________________________________________________________________

NAME POSITION SIGNATURE/DATE

REVIEWED BY:
SIGNATURE/DATE

APPROVED BY: Director of Medical Affairs

SIGNATURE/DATE

Director of Hospital
APPROVED BY:
Program SIGNATURE/DATE

DEPARTMENT REVIEWS:

CODE: SFHM-PUR-FRM-005 ISSUE DATE: 04.01.2015 / ISSUE No.: 1 / REVISION No.: 0 PAGE 2 OF 3
 Kingdom of Saudi Arabia
CAPITAL EQUIPMENT REQUEST FORM Ministry of Interior
General Administration for Medical Service
Security Forces Hospital Program - Makkah

(This section will be completed by the Capital Equipment Committee, do not forward your requests to
these support Departments)

Biomedical
Engineering IT&C Material Planning
Engineering
1. Do you expect 1. Is site modification 2. Will Out-Access 1. Are supplies
support problems? required? Connections be needed to
needed? operate?
 Yes  No  Yes  No  Yes  No  Yes  No
2. Maintenance will be 2. Maintenance will be 2 Are interfaces to 3. Will equipment
provided: provided: other systems duplicate or
needed? eliminate current
 In-house supplies?
 Service Contract  In-house  Other  Yes  No  Yes  No
If question 1 is Yes, If Yes or Other, explain: If question 2 is yes, Explain:
explain: explain:

3. Other 3. Other considerations 3. Other considerations 3. Other considerations

considerations: i.e.,
Risk Rank, Life
Expectancy
Improved patient flow.

4. Cost of following (if 4. Cost of following (if 4. Cost of following (if

required): required): required):
Annual Service Annual Service Annual Service
Contract Contract Contract
Training Training Training
Test/Support Test/Support Test/Support
Equip Equip Equip

NAME POSITION SIGNATURE/DATE

REVIEWED BY: Biomedical Engineer SIGNATURE/DATE

Manager of Material
REVIEWED BY:
Planning SIGNATURE/DATE
Director IT and
REVIEWED BY:
Communication SIGNATURE/DATE

REVIEWED BY: Director of Engineering

SIGNATURE/DATE

CODE: SFHM-PUR-FRM-005 ISSUE DATE: 04.01.2015 / ISSUE No.: 1 / REVISION No.: 0 PAGE 3 OF 3