Appendix 5 Estates Department Request for the Supply of Keys – To: Estates Department insert name of hospital – Date Requested By Position (Print) (Print) Ward/Department Signed and Approved By Department/Service Manager 1. Please supply the following keys - Has a sample key been included? YES / NO Key Quantity Key Key Room Request Location of the lock? required Make number No. Ref. Wansbeck Ward Example 2 UNION G1 5432 Domestic cupboard 23 A B C D E 2. Why are these keys required? Tick as many boxes as is applicable and reference the reason to key request reference above. Request Ref. A - E TICK REASON To replace lost keys To replace broken keys (NOTE please return broken keys with this form). – Broken key(s) herewith YES / NO. – To replace stolen keys To replace keys loaned out and not returned Insufficient keys available The keys are for general use in the department The keys are for personal use (issue to an individual) see below Other State: 3. If the keys are for personal issue to staff, please state the name(s) of the staff: A. D. B. E. C.
Appendix 5 Estates Department – Request for the Supply of Keys To: Estates Department – insert name of hospital Date Requested By (Print) Position (Print) Ward/Department Signed and Approved By Department/Service Manager 1. Please supply the following keys - Has a sample key been included? YES / NO Key Request Ref. Quantity required Key Make Key number Location of the lock? Room No. Example 2 UNION G1 5432 Wansbeck Ward Domestic cupboard 23 A B C D E 2. Why are these keys required? Tick as many boxes as is applicable and reference the reason to key request reference above. Request Ref. A - E TICK REASON To replace lost keys To replace broken keys (NOTE – please return broken keys with this form). Broken key(s) herewith – YES / NO. To replace stolen keys To replace keys loaned out and not returned Insufficient keys available The keys are for general use in the department The keys are for personal use (issue to an individual) see below Other State: 3. If the keys are for personal issue to staff, please state the name(s) of the staff: A. D. B. E. C.