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ANNEX – J A.O. 2012-0012 Name of Health Facility Complete Address
CORRECTIVE MAINTENANCE of EQUIPMENT
Period Covered
Location in the Hospital
Problem Encountered
Action Taken
ex. once quarterly
ex. Ground Floor
ex. Overheating
ex. Repaired
Pneumatic Pump
Boiler
Autoclave
Brand: No. Model: of Serial No.: Items Date Installed:
Prepared by ________________________________ Signature over printed name
Noted by
_______________________________ Signature over printed name
Date
Date
________________________________
________________________________
DOH AO2012-0012 Annex J Corrective Maintenance Eqpt. Revision:00 01/20/2015