Cambridge PCF Form

Cambridge CIR Patient Care Fund Request Form 2009-2010

Please fill out this form in its entirety. If you have questions or would prefer a paper copy of the form, please call the Committee of Interns and Residents at x4-5301

Contact Person

Title

First Name

Last Name

Suffix

Date

/ Month

/ Day

Year

Phone

- ###

#### *

Pager

- ###

####

FAX

- ###

####

Dep't/clinic requesting item(s):

* 'Dep't/clinic requesting item(s):' is required

In-house location of contact person:

(Bldg, floor, rm #)

* 'In-house location of contact person: ' is required

Where item(s) should be sent:

* 'Where item(s) should be sent:' is required

Item

* 'Item' is required

Brief description of item:

(Please attach any descriptive materials)

Reason for request:

(How will this item/service improve patient care?)

How many of these items will you need?

* 'How many of these items will you need?' is required

How many patients will benefit from this item/program within the next year?

* 'How many patients will benefit from this item/program within the next year?' is required

Cost per unit: (Approx.)

* 'Cost per unit: (Approx.)' is required

Total cost:

* 'Total cost:' is required

Maker or vendor:

(If known)

* 'Maker or vendor: ' is required

Vender contact info:

Model/catalogue no.:

'Model/catalogue no.:' is required

Would you accept this item from another vendor?

Yes
No

Have you received a grant from the Patient Care Fund for this item/service in the past?

Yes
No

If yes, when?

'If yes, when?' is required

How many patients were able to benefit from the grant?

'How many patients were able to benefit from the grant?' is required

How did you hear about the Patient Care Fund?

'How did you hear about the Patient Care Fund?' is required