ࡱ>  -bjbj RËË5 &&&&&:::8r\L:$>X\)*Td*,$O,E&*(^:)"**,&&F qX,X,X,*F&&X,*X,X,.LJ*zZ0Ԧ*&**X,*****,,+**************** : FORM B: TECHNOLOGY REQUEST SUPPORT To be completed by Division Chief or Department Head (Local Content Expert) Name of Applicant:  FORMTEXT      (Office use only) EDSP- ID:  FORMTEXT      Department:  FORMTEXT      Division:  FORMTEXT      Phone:  FORMTEXT      Email:  FORMTEXT       Pager:  FORMTEXT      A-1. Name of proposed technology (or trade name if applicable):  FORMTEXT       The Division Chief or Department Head will review Form A: Technology Request, gather input (formal or informal) from other experts (internal or external), and support/not support the Request. Using Appendix I: Technology Assessment Screening Guide, they will ensure that potential issues have been considered. B-1. Division Chief or Department Head [Check ONE]: a.  FORMCHECKBOX  NOT Supported. Please provide reasons for decision.  FORMTEXT        b.  FORMCHECKBOX  Supported for purchase and/or implementation This indicates that the requested technology: represents minor changes from current practice is safe and effective for patient care will improve patient care in the Region has good strategic fit with division/department goals and objectives  c.  FORMCHECKBOX  Supported in principle pending further assessment This indicates that the requested technology: represents a significant change from current practice is likely to be safe and effective for patient care, but needs further assessment may improve patient care in the Region has good strategic fit with division/department goals and objectives  B-2. Comments 6DF    * , . 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