Oregon Community Programs

Oregon Community Programs Equipment Checkout


This form must be completed for any client or family member that is borrowing OCP owned equipment/furniture for the purposes of participating in telehealth sessions from home during OCP office closures.  

 

Client Name:

  :Parent or Guardian Name

 

Equipment Checked Out: (please list all)

 

By signing this form, I agree to the following:

  • The primary use of this tablet is to participate in telehealth sessions with OCP Therapists.
  • The equipment specified above will be used only in the home and will not be taken outside the home, unless otherwise discussed with our primary OCP therapist.
  • I will not lend the tablet to anyone, and when using the equipment specified above, I will follow all of OCP’s confidentiality and HIPAA rules.
  • If I or my children are using the equipment specified above for any reason outside of telehealth sessions with OCP therapists, I agree to supervise their use at all times and ensure no adult or child are accessing inappropriate sites, applications, or materials on the device(s).
  • The protective cover will remain on the tablet at all times.
  • I agree to return all OCP equipment specified above in the same condition in which it was borrowed when the OCP office is re-opened or when requested to do so by a manager.

 

 

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Oregon Community Programs Equipment Checkout
lock iconUnique Document ID: bc2a3b0304e314f3ce1a062256526918b6e64e3a
Timestamp Audit
April 8, 2020 11:09 am PSTOregon Community Programs Equipment Checkout Uploaded by OCP Documents - ocpdocs@oregoncp.org IP 10.0.10.40
April 8, 2020 11:19 am PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:19 am PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:28 am PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:28 am PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:31 am PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:31 am PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:32 am PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:32 am PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 13, 2020 11:28 am PSTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 14, 2020 11:57 am PSTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
January 27, 2021 1:29 pm PSTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.10.43
January 27, 2021 1:29 pm PSTOCP Admin - mindib@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.10.43
April 27, 2021 4:12 pm PSTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
September 14, 2022 12:57 pm PSTOCP Documents - ocpdocs@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.40
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://www.oregoncommunityprograms.org/
Audit Trail Serial# fea5c5ad0bda9db4835f2528ee588978