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 IT EQUIPMENT REPLACEMENT FORM
 

Location Code
Region Code
Provider Code
Business Unit
Speech Therapy
ABA
Occupational Therapy
Other
Role

CURRENT DEVICE INFORMATION

Device Type:
Laptop / Mac
iPad
iPad LTE
Other

E.g 1 Month, 1 Year, etc.

REASON FOR REPLACEMENT

Reason(s):
Business Impact
Low
Normal
High
Critical - Unable to work
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