CHRISTUS Schumpert Health System

Equipment Transfer or Disposition Form

Capital – complete sections 1& 2 and present to Asset Control Team (Tuesday Mornings 8:30 Purchasing Conference Room)
Attach Plant Operation move request form if requesting item be transferred to another department or stored in warehouse (limit 3 months).
Non-Capital – complete sections 1&2 and submit to Purchasing (St. Mary Campus)
Attach Plant Operation move request form if requesting item be transferred to another department or stored in warehouse (limit 3 months)

1. Facility and Equipment Information (completed by disposing department)

St. Mary Place Bossier Highland
Originating Dept. Name: Dept. #: Date:
Department Head Approval: Phone #:
Equipment Description: Manufacturer:
Equipment Works Yes No If no, can it be fixed? Model #:
Inventory Control # (on Biomed Sticker): Serial #:
Original Date of Purchase3 (estimate, if known): Original Cost (if known):

2. Type of Disposition Requested (completed by disposing department)

Reason for Disposition: Replaced with new equipment No longer required Other: .
Type of Disposition: Transfer to following Dept.: Dept. #:
Storage in Following Location: Estimated Time:
Trade in on new equipment (attach to CAF):
Sell to: Requested Selling Price:
Discard:
Donate to:
Notes:

3. Asset Control Team Review

Finance Asset #: Book Value: Recommended Selling Price:
Disposition: Agree with Department Recommendation Disagree with Department Recommendation
Recommended Final Disposition:
Finance: Date:
BioMed: Date:
Plant Ops: Date:
Information Management: Date:
Materials Management: Date:

4. Administrative Approval
Transfer Store Trade in Sell Discard Donate
V.P.: Date: CFO: Date:
*Finance / Treasurer will collect approved forms from Administration and facilitate receipt of funds, if appropriate.

5. Funds Received (completed by Treasurer)

Treasurer: Amount Received: Date:
Accounting: Date:

6. Copy Routing Upon Completion

Finance Disposing Dept. Treasury Biomed Plant Ops
(original for Asset Control) (copy for records) (copy if funds received) (copy for Inventory Control) (copy if move or storage is required)

Rev. Date: 3/05