By Anthony Davis,2014-11-24 08:57
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    CELS Reference No: PPQ

    PRE-PURCHASE QUESTIONNAIRE (Insert Name) COMMUNITY EQUIPMENT SERVICE This form is to provide (Insert name) equipment services with information relating to the needs of prospective

    clients/customers. Please ensure all relevant questions are answered in full.

1. Service to be provided to:

Please complete the following:

Named individual / Service Area / Company details:

     Name: Address: Telephone: Email: Fax:

    2. Please indicate your setting (tick more than one if you are in a section 31 partnership arrangement; please

    indicate partnership ‘host’)

Health Trust

    Local Health Board

    Local Authority under health flexibilities Act Section 31

    Voluntary Sector

    Private Hospital

     GP Practice

    Nursing Home

    Residential Care Home

    Other Please specify

    3. Please state client group you request the service to be provided to:

     Paediatric Services Adult Services

    Learning Disabilities

    Physical Disabilities Mental Health All groups

Other Please specify

BD / CELS / PPQ / June 2007 1


     22 i. Please provide the estimated geographical coverage of the service to be provided Km/Miles

ii. Are there any trend analysis/percentages relating to the expected growth rate? (see below) YES NO

    If you have answered YES to question (ii) please specify details:

     e.g. people over 65 to increase from 20% to 25% of total population in next 5 years


    Please state your overall aims, including relevant key performance issues that you are expecting to provide to your clients

    e.g. help 20% more people to live at home, prevention of admissions. Please provide full details of volumes/percentages

    where appropriate

    6. SERVICE PROVISION - Please tick as appropriate

    Do you require any of the following services?

    i. Delivery and Collection of equipment to and from service users and various nearby sites YES NO

ii. Purchasing of Standard equipment YES NO

    iii. Purchasing of Non-Standard equipment YES NO

iv. Equipment Storage YES NO

    v. Equipment Decontamination YES NO

    vi. Equipment Refurbishment and Recycling YES NO

vii. Use of In-House web based IT ordering system YES NO

    viii. Standard Data and Info Reports YES NO

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     If you have answered YES to question (viii) please specify the exact reports you require

    Report Title Report Details Report Frequency To be sent to

ix. Do you require ad-hoc/bespoke/non-routine reports to be available YES NO

    If you have answered yes please indicate how often you may require these reports:

Once per week Once per month Once per year Other

If you have ticked OTHER please specify:

    Note: there may be a charge for non routine reports.

    7. SERVICE REQUIREMENTS (Note: A comprehensive list detailing equipment types, categories and estimated annual usage for each type and category must accompany this document)

i. Approximate number of items to be issued

    ii. Approximate number of items to be collected

    iii. Approximate number of items to be scrapped

    iv. Approximate percentage of items to be recycled (based on historical data) LOLER: v. *Number of items in use requiring annual planned servicing or inspection PAT:

vi. *Approximate number of new items requiring servicing each year LOLER: PAT:

    *Note it is important you specify the actual numbers for each type of test.

     vii. Number of total activities (deliveries, collections or other visits by technicians)

    viii. Number of bespoke or “special” orders from original equipment manufacturers

    ix. Number of bespoke items to be fabricated by the service provider or items to be

     adapted e.g. wooden ramps or reduced height chairs

    x. For the next twelve month period, what change in demand or issues profile is expected

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     xi. What is the total population within the area of service delivery?

    xii. What postcode regions are to be covered? e.g. CF10 to CF28

    xiii. If there are any cross-border issues to address please provide details:

    xiv. What percentage of total delivery times will be required to be fulfilled within:

    1 day (urgent) 3 days 7 days 28 days Other (Please specify)

xv. Do you require service provision to satellite / buffer stores? YES NO

    If you have answered YES to question (xv.) please specify quantity and locations

xvi. What loan period is the equipment to be issued for? (please tick all that apply)

    Short term (less than 3 months) Medium term (3-12 months) Long term (12 months +)

    xvii. Do you require a recall on your equipment after a specified period? YES NO (if long term a reminder letter can be generated every 12 months)

xviii. If you have ticked YES please specify:

xix. Do you require an out of hours service for the following areas:

    Urgent deliveries maintenance support (by telephone) emergency repair / maintenance call out

     xx. Do you expect the equipment service to deliver and collect all of your equipment? YES NO

    If you have answered NO to question (xx.) please indicate how you will manage your deliveries and collections e.g.

    some clinicians will deliver in their own vehicles

BD / CELS / PPQ / June 2007 4

Additional/Further Information

    Please provide any additional information you feel Community Equipment Services need to know in order to provide

    your service


    a. How is your equipment budget managed?

    i) Budget Manager please provide name

    ii) Pooled funding arrangement (Section 31) If you answer YES to ii or iii please provide iii) Aligned budget partnership details:

    iv) Other please specify

b. Please provide budget amount

    c. How do you propose managing the equipment budget? - (equipment services will ensure that all equipment will be purchased, stored, issued and recycled as efficiently as possible, but will not be responsible for managing the

    equipment budget. This will be the entire responsibility of budget holders)

Clinical equipment resource team

     Pooled budget manager

Designated budget holder

Please provide details i.e. name and contact details

     Name: Address: Tel: Email: Fax:

    e. If you are part of a pooled funding/aligned budget arrangement, do you have cross charges in place? YES NO

    If you have answered YES please to question (e ) specify how you expect to manage this

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f. Is there any financial info you need the equipment service to capture? YES NO

    If you have answered YES to question ( f ) please specify


    Please state how often you would like to be invoiced:

     Monthly Quarterly

Please provide a name and details for invoicing:







    (Insert name) Community Equipment Services WILL NOT be responsible for any associated risks, service requirements or

    financial liabilities resulting from the lack of information detailed in this PPQ.

I have read and understood the above PPQ and agree that I have provided the service requirements for my area of

    responsibility. I also agree that any service requirements missed on this PPQ will not be the responsibility of the

    provider unless otherwise negotiated and agreed at a later stage.

Completed by:



Countersigned by:



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    Official use only

     For CELS purpose only:

Assessed by:

    Job title:



    Special / Additional requirements (include growth and forecasts)

    Resource allocation requirements (include growth and forecasts)

Feasibility scoring:

    Not possible 1 2 3 4 5 Possibility

     Can CELS provide this service? YES NO

     If NO please state the reason

Duration of service agreement

Commencement date

    All of the above has been agreed and authorised by:


    Job Title:



    BD / CELS / PPQ / June 2007 7

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