Equipment loan request form

Current Details of person with MND
Details of requesting professional
Details of Equipment Loan Request
Funding by statutory agencies or others
Final details
Complete

The MND Association cannot use its resources to replace statutory responsibilities. In completing this application form, health and social care professionals should include supporting documentation demonstrating efforts made to secure statutory provision. In signing this application form the professional confirms every effort has been made to seek statutory and other appropriate resources.

We will not process incomplete forms. Referring professionals must ensure applications are fully completed and returned in a timely manner. Please include ethnicity according to Department of Health coding.

If you have any queries about this application process, please email [email protected]

Details of person with MND

Title

First name

Last name

Date of birth

Address of person with MND

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone

Gender

Ethnicity Code

Sexual Orientation

Religion

Date of diagnosis

NHS Number

If known.

GP's name

Address of GP

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

First name of requesting professional

Last name of requesting professional

Job title

Address of professional

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Confirmation email will be sent to this address.

Phone

Normal working hours when you can be contacted

Contact details of a colleague who can be contacted if you are unavailable

First name

Last name

Phone

Please note: We are only able to loan iOS apps. If the person has an Android or Windows device and you are applying for an app only, you need to complete an MND Support Care Grant application form to apply for funding towards the app.

Items requested with details of specification:

If requesting an iPad, you need to state the AAC app that is required on the iPad. Please note that we will only provide one app:

Does the person have their own iPad/iPhone:

Yes

Delivery address for equipment

Address 2

City/Town

State/Province

Postal Code

Country

Phone

If requesting the loan of an iPad and Grid for iPad app, we will be required to set up a Smartbox account using the person with MND’s email address. Please confirm that consent has been given by the person with MND for us to do this on their behalf:

Yes

Please note: This section is mandatory. As a charity, we require details as to why statutory services/The NHS is unable to provide suitable AAC. Failure to complete this section fully may cause the application to be delayed.

Please give detail of what attempts have been made to secure the equipment/funding from the statutory services

Reason why this need cannot be met by statutory services. For all equipment requests, please provide a rationale for why you are applying

If the equipment or service IS available from statutory services but there is a waiting list please state the date the equipment or service is likely to be available

Details of other charities or organisations that have been approached for funding. If the person with MND has already been referred to an AAC Specialist centre, please let us know.

Any other information relevant to the application

Please give details.

Statement by the referring professional

If this application is approved, I understand that, unless otherwise agreed with the support services team:

Where appropriate, it is my responsibility to continue to pursue funding from statutory services
It is my responsibility to monitor and assess the ongoing needs of the person with MND in relation to this application.
It is my responsibility to notify the relevant statutory service that the MND Association has provided equipment loan services to a person with MND
Should I leave my current post, I will notify the MND Association of the name of the professional who has taken on the responsibility for ongoing communication and liaison with the MND Association
I will monitor suitability, provide any necessary instruction, and will notify you when equipment is no longer needed.
I will ensure that loaned equipment is returned in a timely manner when it is no longer being used.

Please tick the boxes below to confirm you have read the statement above

I agree to everything stated in the form above

I have read the MND Association Privacy Policy.

Date

The Association will follow procedures for recording, storing, and updating personal information all of which will comply with the Data Protection Act 1998 and any subsequent legislation including the General Data Protection Regulation. We may occasionally share your information within the Association and with local health and social care professionals where it helps with your care and support or with development of better services. If you have already expressed a preference for future contact we will follow these, if not, we may ask you for your views on how our services might be improved. If you do not want us to be in contact, please let us know on [email protected]

Please see our privacy policy for full details of how we use your information.

In making this application I consent to:

This application being made for/on my behalf
Details of this application being held on record by the MND Association

I also confirm I have answered all questions.

Details of person with MND

Details of person with MND

Details of requesting professional

Details of requesting professional

Contact details of a colleague who can be contacted if you are unavailable

Details of Equipment Loan Request

Funding by statutory agencies or others

Final details

Section 1

Statement by the referring professional