Form On Corrective Maintenance of Equipment [PDF]

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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