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TRIMEDX Device Disposition Request Form

The document is a Disposition of Equipment Form completed by Andrew Moore, a Biomedical Technician III, requesting the disposition of a device due to it being unlocatable. The device, identified by CEID number 31953479 and manufactured by Stryker Medical, is confirmed to not contain electronic protected health information (ePHI). Authorization for the disposition is required from the Hospital Authorizing Agent, which is indicated in Section 3 of the form.

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74 views1 page

TRIMEDX Device Disposition Request Form

The document is a Disposition of Equipment Form completed by Andrew Moore, a Biomedical Technician III, requesting the disposition of a device due to it being unlocatable. The device, identified by CEID number 31953479 and manufactured by Stryker Medical, is confirmed to not contain electronic protected health information (ePHI). Authorization for the disposition is required from the Hospital Authorizing Agent, which is indicated in Section 3 of the form.

Uploaded by

Molson 5150
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

6/10/25, 2:45 PM RSQ

DISPOSITION OF EQUIPMENT FORM

SECTION 1 To be completed by Disposition Requestor


Requestor Name Andrew Moore

Requestor Title Biomedical Technician III

CEID Number of device requested to be dispositioned 31953479

Could Not Locate Facility Closing


Excess Inventory RUDR Recommendation Temporary Device
Reason for dispositioned (CNL)

Network / OS Issue Traded-In/Sold Unrepairable Other:


RSQ Data Correction

Could Not Locate (CNL) Donated Returned Sold Traded In


Type of disposition
Reallocated Recycled RSQ Data Correction Other:

SECTION 2 To be completed by TRIMEDX


No  Notify Hospital Authorizing Agent & TRIMEDX Manager
Was the device in an ACTIVE
status in RSQ?
Yes  Confirm device information below

CEID Number 31953479 Serial Number SVP267F0216

Manufacturer STRYKER MEDICAL Model 63481

Asset Tag

DISPLAYS VIDEO
Description

No  Complete Section 3 Only


Does the device contain ePHI? Yes  Skip Section 3; Proceed to Sections 4-6

SECTION 3 To be completed by Hospital Authorizing Agent


I authorize the disposition of CEID Number: 31953479
I confirm that the device does NOT contain ePHI

HAA Name

HAA Title

Date 2025-06-10

Signature

Only one section from Sections 4-6 should be completed, based on the situation:
Section 4: Device located & ePHI storage media present
TRIMEDX CONFIDENTIAL
[Link] 1/5

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