Equipment Reservation Form

Psychiatry faculty/staff may reserve equipment based on availability. Requests from faculty/staff outside of the department will be considered on a case-by-case basis (Department of Psychiatry faculty/staff requests take priority). A minimum of 3 business days is required to process requests. Equipment must be checked in/out within standard operating hours, 8am - 5pm, Monday - Friday.

Equipment

The following equipment may be reserved: Camera (recording capability, accessories available) iPad (up to 5 may be reserved at a time) Laptop (Mac + PC)

Item Requested*

Choose from list below.

Select

Requestor*

The requestor takes sole responsibility for all equipment/accessories checked out.

Quantity*

Only iPads may be requested in quantities > 1.

Begin Date*

Enter pickup date.

Expected Return Date*

Enter expected return date.

Accessories Requested*

Edit the default list below.

Overnight Use*

Is this an overnight equipment request? If checking out overnight, securing all equipment/accessories in a locked room, cabinet, or safe is required.

Location of Use*

Where will the requested equipment be primarily used?

Purpose of Use*

Provide general purpose for equipment request.

Terms and Conditions

This form assigns primary responsibility for Department of Psychiatry equipment to the borrower. The borrower will be responsible for taking the necessary precautions to protect the equipment and to store it in a manner that provides adequate protection, thus not subjecting the equipment to possible theft or damage. 1. The borrower will be responsible for return of the equipment in the same condition it was received. 2. If loss or damage of the equipment/property occurs and determination is made that the loss or damage is a result of negligence, the borrower may be held financially responsible for the repair or replacement of the item(s). Reimbursement to the department by the borrower who checked the equipment out should be at the fair market value of the equipment/property at the time of loss. 3. Equipment may not be taken off of campus nor loaned/transferred to a third party. 4. The borrower may not modify the equipment in any way. 5. The borrower will make the equipment available at any time as requested by the department.

Acknowledgement*

Electronic Signature of Acknowledgement (typing your name below serves as your signature):

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