Humpty Dumpty Foundation Suite 1402, 67 Albert Ave Chatswood NSW 2067 T 02 9419 2410 www.humpty.com.au

ABN 59 137 784 724

Service Head/Department Head Declaration Form

Humpty Dumpty Foundation (‘Humpty’) requires that Applications for Equipment be approved by the Applicant AND by the appropriate Service Head or Department Head of the Hospital or Health Service submitting the Application. Both the Applicant and the Head must read, sign and date the Declarations below. Declaration by Applicant

I certify that the application #.................. for ........................................................................... (name of Equipment)

created on ........................ (date) for ...................................................... (Hospital/Service) is accurate and correct.

Applicant Name: ............................................................... Position: ............................................................. Signature: ............................................................................. Date: ................................................................. Declaration by Service/Department Head

1. I declare and confirm that: a) This Application for Equipment is accurate and correct and is supported by me. b) The Equipment is necessary and will be used in Children’s Services. c) The Equipment principally promotes the prevention or control of diseases in children. d) This Application and the Equipment is consistent with the clinical policy of this Hospital/Service. e) Use of the Equipment complies with all relevant State Health Authority guidelines. f) The biomedical engineering or the equivalent equipment maintenance service department of this

Hospital/Service has approved this Application. g) Other potential sources of funding, particularly the Area Health Service, have already been

approached to provide the Equipment and have declined. 2. I understand and agree that:

a) The ongoing costs for the Equipment including training, insurance, warranty, maintenance and consumables are the responsibility of this Hospital/Service.

b) Humpty may use the name of this Hospital/Service for promotional purposes. c) If this Application is approved, the Equipment will be placed on Humpty’s Wish List for Donors to

purchase. Until a donor is found, the Equipment is not to appear on any other provider’s wish list and this Hospital/Service shall immediately notify Humpty if the Equipment is no longer required.

d) For ongoing special projects, the maximum term of Humpty’s commitment is 12 months. For renewed funding, a new Application must be submitted and reviewed.

e) Humpty will provide a sticker acknowledging the Donor which must be placed on the equipment. A photo of the stickered Equipment should be sent to Humpty where possible to share with the donor.

f) If the Donor would like to visit the Hospital/Service to see their donated equipment, the Hospital/Service must take all reasonable steps to accommodate them.

g) At no time will the Hospital/ Service contact Humpty’s donor directly - this will jeopardise any potential future Humpty funding.

Service/Department Head Name: ............................................................... Position: ....................................... Email: ......................................................................... Contact Phone: ( ) .................................................... Signature: ............................................................................. Date: .............................................................