International SOS

PT. ASIH EKA ABADI

Medical Services - Rental Equipment Timesheet

SITE NAME : HEXINDO - Jambi Period: November 2016

Days

QTY
Clinic Equipment Name Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

RESUSITATOR PORTABLE 175-010 LSP 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30

OXYGEN CYLINDER LSP 400/ 415 LT 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
RESCUE PUMP/HANDLE COMPLT AMBU 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
NASAL OXYGEN CANULA ADULT 1820 2 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
REBREATHING MASK ADULT # 1007 2 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
BASKET STRETCHER FERNO 71S 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
VACUUM MATTRESS FERNO 192 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
SCOOP STRETCHER # 65 EXL FERNO 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
SPINAL BOARD FERNO+BELT/3 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
FERNO HEAD IMMOBILIZER #445 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
FERNO K.E.D. MODEL 125 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
TRACTION SPLINT FERNO ADULT# 444 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
STIFFNECK SELECT ADJUSTABLE ADULT#980010/12 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
STING & BITE AID KIT # FAB -SBK PENTAMED 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
DIAGNOSTIC SET WA # 97150BI 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
BLOOD PRESSURE RIESTER-MOVEABL 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
STETOSCOPE LITTMANN ADULT ( CLASSIC II ) 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
LOUPE OPTIVISOR DA 5 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
INFUSION STAND MAK 36101S/S 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
KIDNEY DISH LARGE 2 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
RING CUTTER GERMANY 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
LARYNGOSCOPE ADULT RIESTER 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
BED PAN + COVER PLASTIC 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
URINAL PLASTIC MALE+COVER 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
SCALE /HEIGHT-WEIGHT 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
MINOR SURGERY SET 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
Legend : X : On SITE T : Travel from / to Site

Prepared by MS Operation Confirmation Client Representative

Name : Name / Job Title : ______________ Name / Job Title : _________________

Signature : ______________________ Signature : ______________ Signature : _________________

Date : 30 November 2016 Date : ______________ Date : _________________
 International SOS
PT. ASIH EKA ABADI
Medical Services - Rental Equipment Timesheet

SITE NAME : HEXINDO - Jambi Period: November 2016

Days

QTY
Clinic Equipment Name Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
SHARP BOX CONTAINE 7,6L YELLOW 2 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
IIMS BOOK 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
BODY BAG LIGHT 3 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
ZOLL , AED PLUS UNIT 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
PULSE OXIMETRY TUFFSAT 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
NEBULIZER DEVILBISS 5650I PULMOAIDE 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
MAGIL FORCEP ADULT 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
STERILIZER , DRY TYPE MELAG 75 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
EXAMINATION HALOGEN LAMP 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
OXYGEN CYLINDER 1,5 M3 TYPE D ( ALUMUNIUM ) 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
OXYGEN REGULATOR + FLOW METER HUMIDIFIER SHARP JAP 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
ELECTRIC SUCTION UNIT LAERDAL -780000 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
ISHIHARA BOOK 14 PG 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
SNELLEN EYE CHART PAPER 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
REFRIGERATOR 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
PARAMEDIC RESPONDER BAG ( INSIDE CLINIC ) 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
ECG CARDIOTOUCH 3000 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
PATIENT MONITOR COMEN STAR-8000 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
EXAMINATION TABLE MAK# 34101 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
EMERGENCY TROLEY MAK 2 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
MEDICINE CABINET 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
DRESSING TROLEY MAK 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
CLINIC CONTAINERT 20 Ft 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30

Legend : X : On SITE T : Travel from / to Site

Prepared by MS Operation Confirmation Client Representative

Name : Name / Job Title : _______________ Name / Job Title : _______________

Signature : _________________ Signature : _______________ Signature : ________________

Date : 30 November 2016 Date : ___________ Date : _______________
 International SOS
PT. ASIH EKA ABADI
Medical Services - Rental Equipment Timesheet

SITE NAME : Hexindo - Jambi Period: November 2016

Days

QTY
Ambulance Equipment Name Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
AMBULANCE FORD RANGER 4x4 (Unit) 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
SCOOP STRETCHER # 65 EXL FERNO 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
SPINAL BOARD FERNO+BELT/3 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
WOOD SPLINT DYNAMED C/N 95771 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
FERNO HEAD IMMOBILIZER #445 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
TRACTION SPLINT FERNO ADULT# 444 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
ELECTRIC SUCTION UNIT LAERDAL -780000 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
FERNO K.E.D. MODEL 125 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
NEBULIZER DEVILBISS 5650I PULMOAIDE 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
RESUSITATOR PORTABLE 175-010 LSP 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
INTERNATIONAL SOS RESPONDER BAG 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
ZOLL , AED PLUS UNIT 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 30
Legend : X : On SITE T : Travel from / to Site

Prepared by MS Operation Confirmation Client Representative

Name : Name / Job Title : _______________ Name / Job Title : _______________

Signature : _________________ Signature : _______________ Signature : ________________

Date : 30 November 2016 Date : ___________ Date : _______________