Request Loan of GE Achilles Bone Density Machine

Please complete this form to request loan of GE Achilles Bone Density Machine for your upcoming US Healthy Athletes Health Promotion Event.

If you have any questions, please email healthpromotion@specialolympics.org

Contact Information

Special Olympics Program Name

Screening Event Dates

Please enter month, day and year -- i.e., 05/20/2022

HP Clinical Director

HP Clinical Director Email

How many athletes do you anticipate screening?

Shipping Information

The person listed below will guarantee the machine will be protected from theft; stored and used in an appropriate environment; and use will follow instructions in the Health Promotion Clinical Directors Manual 2015. Additionally, this person will be responsible for assuring return of the equipment within 24 hours following close of the screening event; as per the detailed repacking instructions.

Name and Title

Shipping Address

Phone

In-hands date

Date you need to receive the bone density machine by. This date should be no more than 5 business days before the event date.

mm/dd/yyyy

Return shipping date

*This must be within 24 hours of event date*

mm/dd/yyyy

Return Shipping Preference

Special Olympics PROGRAM will refer athletes with low bone density to their health care provider for follow up on the identified condition. A description of our programs’ plan is included with this Bone Density Machine request form. I will submit a brief report of the outcome of these referrals within 3 months after the event.

After use, repack the machine EXACTLY as instructed to avoid costly damages. Return machine according to the GE representative’s information. Ship the machine out within 24 hours after the close of your event so the equipment will be available for the next programs’ event. Follow “repacking GE” instructions including purchase of insurance for the Achilles (medical equipment) for $10,000.

Ship machine by FedEx/UPS to:

ASAPfast!

44180 Mercure Circle

Dulles, VA 20166

NOTE: Please email the tracking number to healthpromotion@specialolympics.org.

Acknowledgement

By checking the box, I acknowledge the above statement to refer athletes and to submit a brief report.

Thank you and please reach out if you have any questions!

Send me a copy of my responses

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