Appendix B "Donation Tracking - Quality Checklist/Description" - Missouri

What Is Appendix B?

This is a legal form that was released by the Missouri Department of Mental Health - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2010;
  • The latest edition provided by the Missouri Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Appendix B by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download Appendix B "Donation Tracking - Quality Checklist/Description" - Missouri

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Appendix B
Quality Checklist/Description
Item being donated: ___________________________Donated by: _________________________
Checked in by:
Date:
Checked out by:
Date:
Please check all that apply:
MANUAL WHEELCHAIR:
size of chair _________________
BATHSEATS:
age of chair_________________________
____non skid tip on each leg
weight bearing limit for chair (lbs)__________
____all latches and buttons lock and work properly
____wheel locks engage tires properly
on height adjustments
____footrests present and in working order
____seat surface is free from defects, which could
____upholstery in good condition
cause scratching or pinching to user
____attaching hardware present and working
____seat bears weight of person who uses it
____seatbelt/restraining straps in good condition
____seat is clean and in good condition
____wheels in good condition
____casters in good condition
____frame in good condition
HOSPITAL BEDS:
____mattress is clean and in good condition
____handgrips present
____handgrips firmly attach to chair
____hypoallergenic cover
____chair folds properly
____mattress fits bed (correct size for frame)
____seat rail guides present
____complete set of side rails
____seat rail guides are working properly
____bed, including head and foot, raises and lowers
____removable arms come off for transfer
properly
____elevating leg rests lock in place when raised
____crank handles are present
____handrails attach securely to wheels
____crank handles are working properly
____handrails are free from loose chrome or rough
____bed wheel locks engage properly to steady bed
for transferring
areas
____chair has attachments to keep it from tipping
____pneumatic tires hold air properly
____pop off wheels lock securely in place on chair
ELECTRIC BEDS: (additional information)
____wheels are adjusted properly
____bed has properly working backup crank
____wheelchair is clean and in good condition
POWER CHAIRS (additional information):
HOYER LIFTS:
Age and type of battery____________________
____wheels lock in place during transfer
____pump does not leak and holds pressure
____all caps are present
____battery connections are free from corrosion
____legs of base open properly to allow lift to fit
around chair
WALKERS:
____sling chairs are present
size of walker ____________________
____sling is clean and in good condition (no
____non skid tip on each leg of walker
defects, tears or rips)
____all latches work in folding walker
____for bathroom use: sling is a commode type
____all latches and buttons lock and work properly
____wheels on base roll freely and easily
on height adjustments
____handgrips are firmly attached
____walker is clean and in good condition
1.030 Donation Tracking Policy
06.01.10
Appendix B
Quality Checklist/Description
Item being donated: ___________________________Donated by: _________________________
Checked in by:
Date:
Checked out by:
Date:
Please check all that apply:
MANUAL WHEELCHAIR:
size of chair _________________
BATHSEATS:
age of chair_________________________
____non skid tip on each leg
weight bearing limit for chair (lbs)__________
____all latches and buttons lock and work properly
____wheel locks engage tires properly
on height adjustments
____footrests present and in working order
____seat surface is free from defects, which could
____upholstery in good condition
cause scratching or pinching to user
____attaching hardware present and working
____seat bears weight of person who uses it
____seatbelt/restraining straps in good condition
____seat is clean and in good condition
____wheels in good condition
____casters in good condition
____frame in good condition
HOSPITAL BEDS:
____mattress is clean and in good condition
____handgrips present
____handgrips firmly attach to chair
____hypoallergenic cover
____chair folds properly
____mattress fits bed (correct size for frame)
____seat rail guides present
____complete set of side rails
____seat rail guides are working properly
____bed, including head and foot, raises and lowers
____removable arms come off for transfer
properly
____elevating leg rests lock in place when raised
____crank handles are present
____handrails attach securely to wheels
____crank handles are working properly
____handrails are free from loose chrome or rough
____bed wheel locks engage properly to steady bed
for transferring
areas
____chair has attachments to keep it from tipping
____pneumatic tires hold air properly
____pop off wheels lock securely in place on chair
ELECTRIC BEDS: (additional information)
____wheels are adjusted properly
____bed has properly working backup crank
____wheelchair is clean and in good condition
POWER CHAIRS (additional information):
HOYER LIFTS:
Age and type of battery____________________
____wheels lock in place during transfer
____pump does not leak and holds pressure
____all caps are present
____battery connections are free from corrosion
____legs of base open properly to allow lift to fit
around chair
WALKERS:
____sling chairs are present
size of walker ____________________
____sling is clean and in good condition (no
____non skid tip on each leg of walker
defects, tears or rips)
____all latches work in folding walker
____for bathroom use: sling is a commode type
____all latches and buttons lock and work properly
____wheels on base roll freely and easily
on height adjustments
____handgrips are firmly attached
____walker is clean and in good condition
1.030 Donation Tracking Policy
06.01.10