EQUIPMENT PERFORMANCE

Name of the unit

:
___________________________________________
Location of unit
: ___________________________________________
Model #
Serial Number #
Monitoring done by

: ________________________________
: _____________________________
:
Third party

NKTI GSD

In-house

______________
______________
______________

Pre-procedural
1. Unit in good condition during the visual inspection

YES NO

If NO then state the reason

not on its usual form with unusual sound with unusual odor other _____
Reported

to whom

_____________

Ignored

reason ______________

2. Unit ready for use after the initial testing

YES NO

If NO then state the reason

not properly cleaned-up no power other __________________________

Reported

to whom

_____________

Ignored

reason ______________

End here if no Post-procedure done.

Post-procedural
3. Unit has completed its sequence without error/s
If NO then state the reason

Reported

to whom

YES NO n/a

__________________________________________

_____________

Ignored

reason ______________

End here if no error/s encountered.

4. Unit has performed its sequence but encountered error/s due to YES NO
If yes, please discuss the error encountered in the box provided below.
unit itself linked device ____________ other _____________________

Please discuss, in detail, the nature of error:

Reported to whom _____________

Ignored

reason ______________

5. Unit has failed to complete its/any sequence YES NO

If yes, please discuss the error encountered in the box provided below.
unit itself linked device ____________ other _____________________

Please discuss, in detail, the nature of error:

Reported to whom _____________

Ignored

reason ______________

============================================================================
Monitoring Done By / Signature / Date : _______________________

Verified by / Signature / Date

: _______________________

daily,
yearly,

monthly,
other ________