Request Mitigation – Mitigate Events

Contract Name PFI

This form is for the sole use of Service Providers to request mitigation for Events which may become failures as a result of denied access or specialist parts being required.

By using this form you agree to the Terms of Use.

Your Contact Details

Requester Name *

First

Last

Requester Email Address *

Event Reference *

Event Description *

What areas are affected by the Event? *

What impact is the Event having on the normal operation of the affected areas? *

What increased risk is there to the health, safety and welfare of patients, visitors and staff? *

What impact does the Event have on the environmental services in the affected areas?

Priority *

Rectification Due Date and Time *

Request for Mitigation

Mitigation Type *

Denied Access
Parts / Labour

Name of Specialist Contractor *

Specialist Part and/or Labour Required: *

Why can the Event not be rectified within the Rectification Time? *

Has a Temporary Repair been implemented? *

A Temporary Repair needs to satisfy the Accessibility Condition, Safety Condition and either the Prescribed Health or Operational Function Condition as well as substantially making good the relevant Service Failure.

What is the nature of the Temporary Repair? *

Is the Head of Department happy with the Temporary Repair?

Why is the Happy of Department not happy with the Temporary Repair? *

Head of Department Name *

First

Last

Head of Department Email Address *

Does the Temporary Repair require a derogation of the Availability Conditions? *

The person denying access is *

Present
Not Present

Person Denying Access Name *

First

Last

Person Denying Access Email Address *

Reason for Denying Access *

Further information for denying access (optional)

Has an access date been agreed? *

Why has an access date not been agreed? *

Agreed Access Date *

Date

Time

What is the proposed Rectification Date? *

Date

Time

Supporting Images

Click or drag files to this area to upload. You can upload up to 3 files.

I hereby declare, that all of the information I have provided is complete and correct. *

Confirmed