Tags: Guidance, Toolkit, Template

16th March 2021



DSC 3578

Thank you to Nuria De Miguel from Central & North West London NHS Foundation Trust for sharing.

Completion of this form is required to ensure that equipment is only accessed by authorised individuals and used in an appropriate manner. We require your signature to confirm that you are aware of the risks and will adhere to the responsibilities set out below.

The device provided is for your sole use, and it is your responsibility whilst in your care. You agree that this equipment is to be used only for the tasks relevant to your role or projects you are involved in, e.g. making calls for Check in and Chat or other volunteer-related projects as agreed with the CNWL Volunteer Service.

Purpose of the loan

We support volunteers, carers, service users and other key stakeholders of CNWL Trust in their roles and projects. When needed, we will provide them with an electronic device for an agreed length of time. They will use this device as needed for the role/ project they are part of, for example to access the internet, or to communicate and engage with service users or staff.

Your responsibilities

It is your responsibility to ensure that you look after the device whilst it is in your care, so it can be loaned out to others in the future. We expect you to:

  • Make sure the device is kept safe at all times.
  • If possible, to use it only in your home environment
  • Do not allow any other person (family member, friend or children) to have access to and use the device.
  • Use the device to access the websites/ apps/ features that intended to be used as part of your role/ project.
  • Not to access websites that will trigger a safeguarding alert, such as pornography, extremist or dark websites.
  • Ensure that no personal data is saved on the device and please wipe off anything that you saved on the device before returning to CNWL.
  • Handle your device with care and respect, keeping it in its protective cover (if it has one) avoiding all damage and using only approved cleaning materials suitable to clean your device.
  • Return the device within 7 days from CNWL’s request or when the loan period terminates.


The device is issued to you only to support in your role/ project. Where the Trust identifies that use of the device has been inappropriate, or if a safeguarding issue is raised or when you are unable or unwilling to return the device, we will follow the actions below:

  • Safeguarding: If there is an immediate danger to others or to you then a safeguarding alert will be made to the safeguarding team, depending on the alert this may lead to the police being informed. This may be due to accessing pornography, dark web websites, chat websites or any other websites that will compromise the Trust’s Data policy, and potentially put you or your family at risk.
  • Missing device through profit making: Where we identify that the device has been intentionally sold for profit making, we will inform the police as this is theft. Individuals may be prosecuted and this will also lead to being discharged from your role/ project.
  • Tracker: If the device is reported missing the CNWL IT team may have a tracker in place to locate it.
  • Careless use: If a device is left in your vehicle while you are absent, or left on public transport or a shop and it is stolen, then this cost may be applied to you. Similarly, if the device is returned not in the same condition that it was provided to you the cost of damage and repairs may apply to you.
  • Unlawful use of the Internet: The level of internet usage will be monitored. Where we identify that you are streaming movies or music or anything that is not related to your role/ project or has not been agreed by CNWL, then we will collect the device from you.

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