Annexes

Annex A: Sample of Medical Equipment Inventory Data Collection form

Name of Hospital: - ______________________________; Department /ward Name: - ………………………

1. Date of Inventory:
2. Inventory code number: -
3. Type of Device
4. Manufacturer
5. Model/ Ref
6. Serial No,
7. Country of origin
8. Year of manufacture
9. Power requirement 220V 110V 380V NA
10. Current state/Condition Operable and in use
Operable and out service
Reason out of service:- _______________________________
______________________________________________
Needs maintenance
Not repairable
Needs discharge Yes, No
11. Spare parts available? Yes, No
If yes, what/how many/where are they located:- _______
______________________________________________
12. Manual Available User manual:- location:- _____________________
No, of copies:- ____________________
Service manual:- location:- __________________
No, of copies:- ___________________________
13. Equipment user Doctors Nurses
Lab Technician Students
Residents
14. Current location of equipment:- ______________________________________________
15. Will it move from here Yes, No
If so,where? __________________________________

Name of committee data collected: -

NAME
1. _________________________
2. ________________________
3. ________________________
4. ________________________
5. ________________________
SIGN DATE_______________
_____________ ______________________
_____________ ______________________
_____________ ______________________
_____________ ______________________
_____________ ______________________

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