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                                                                                                      INVENTORY CONTROL
                                                                          "PROPERTY LOAN REQUEST FORM" - IC-5A

MAIL ENTIRE PACKAGE TO:      Inventory Control,  Building J,   MC 6170                                                  Phone:   679-1952    
NAME:    
BUILDING: FLOOR: ROOM  #:      TEL. #:      
DEPARTMENT:
MAIL CODE:  MC         E-MAIL: 
LOAN TYPE:                        INSTRUCTIONS, PLEASE READ:   dotblink.gif (1956 bytes)
1.
      Loan Property from One
      Department to Another. 		2.  
      Loan Property from UCHC
      to Another Institution.		 3.  
      Loan Property from UCHC to an
      Individual.		 4.   Other:  (Explain)
     
PURPOSE:
SPECIAL TERMS OF AGREEMENT:  

HC #

DESCRIPTION

 CONDITION

VALUE

REMARKS
DATE OF AGREEMENT:          ESTIMATED RETURN DATE:    (NOT TO EXCEED ONE YEAR)

REMARKS: 

CODING:

FISCAL YR

LEDGER

ACCOUNT

SUBCODE

AMOUNT

AUTHORIZED SIGNATURE
 

________________________

IMPORTANT NOTICES TO DEPARTMENT HEAD:

  1. YOUR SIGNATURE ALSO CONFIRMS THAT ALL EQUIPMENT & ACCESSORIES USED WITH/OR HAVING CONTAINED RADIOACTIVE OR OTHER HAZARDOUS MATERIALS HAVE BEEN INSPECTED & APPROVED FOR SHIPPING AND/OR STORAGE BY ENVIRONMENTAL & RADIATION SAFETY.
     

  2. YOUR SIGNATURE ALSO CONFIRMS THAT ALL ELECTRONIC STORAGE EQUIPMENT & DEVICES HAVE BEEN PROPERLY CLEANED OF INFORMATION ACCORDING TO UCHC HIPAA POLICIES.

AUTHORIZED SIGNATURES    (Signatures Must Be In Order Stated)
1.  RECIPIENT OF LOANED PROPERTY:  ___________________________________________________     DATE:  ________________
      PLEASE PRINT NAME ALSO:                 ___________________________________________________
RELEASED BY:    RECEIVED BY:   (ON RETURN)                             
                                                                           ACTUAL DATE RETURNED:		 _______
DATE
___________________________
1.  DEPARTMENTAL PROPERTY COORDINATOR		 _______
DATE		 ___________________________
1.  DEPARTMENTAL PROPERTY COORDINATOR		 _______
DATE
___________________________
2.  DEPARTMENT HEAD		 _______
DATE		 ___________________________
2.  DEPARTMENT HEAD		 _______
DATE
___________________________
3. INVENTORY CONTROL		 _______
DATE		 ___________________________
3. INVENTORY CONTROL		 _______
DATE
_____________________________
4. DIRECTOR OF  MATERIALS MANAGEMENT
   (All Asset Transactions)		 _______
DATE

___________________________
4. RECIPIENT'S SIGNATURE

_______
DATE

Please make sure all information is correctly filled out.

   

If additional room or special instructions are necessary, please submit on 8-1/2 x 11' paper and send to Inventory Control, MC 5331. At the request of the Police Department:   When removing property from the Health Center be sure to have a copy of the fully executed IC-5A form on hand for verification.  This policy will be enforced. If you have any questions regarding this form, please call the UCHC Inventory Control Officer at 679-1952.

 

OPMM USE ONLY
RECEIVED BY:     
INITIALS: ________ 
TIME: ________  
DATE:  __________		 REQUEST IS: 
APPROVED:   
DENIED:       		SCHEDULED REMOVAL DATE: 

____________		 COMPLETED BY:   
INITIALS: ________ 
TIME: ________    
DATE:  __________

                               MAKE A COPY FOR YOUR FILE

IF YOU NEED ASSISTANCE COMPLETING THIS FORM, CALL 679-1952    REFERENCE # G Hit Counter