Medical Equipment Work Request

To complete request, tab into each block and fill in the appropriate information.  Thank you.
 

Contact:

Person to Contact: 

E-mail: 

Phone Number: 

Equipment Information:

Location of Equipment: 

Equipment Number (Clinical Engineering Number):

Problem:  (check all that apply)

  Cable/cord defective  

  Out of calibration

  Does not turn on/No display  

  Temperature not working

  Does not pass weekly test

  Will not heat or cool

  Needs batteries

  Will not transmit

  Occlusion alarm

  Other: (Please explain below and be specific)

Priority Code:    Emergency     Routine

Note:  Broken, out-of-order, or not working are not acceptable to explain problem.  Please be specific.  Thank you.