Annex H – Work Order Form

section A: To be completed by user

Equipment Name: - _________________________ Inventory Number: - ___________________________

Ward name: - ____________________________ Item Location: - ____________________________

Name of person making request: - ___________________________ Sign_________ Date: -_________

Description of Problem: - ____________________________________________________________________

Troubleshooting performed (if relevant):- _______________________________________________________

section B: To be completed by Head of Equipment Maintenance

Work order number: - __________________________
Date request received: - _____________________
Task allocated to: -
………………………………………………….
Priority of task High Medium Low

section C: To be completed by Maintenance Technician

Was item repaired? Yes No
If Yes, complete Maintenance Report / Corrective If No, state reason work not completed and return Work
Maintenance Form. Return Item to User. Order Form to Head of Equipment Maintenance for follow
up and completion of Work Order (by assigning another
Equipment returned to___________________
technician or outsourcing):
Date returned __________________________
………………………………………………………………
………………………………………………………………
Maintained Engineer/Technician: -
1. _________________________ Signature: ____________ Date: - ________
2. ________________________ Signature: ____________ Date: - ________
3. ________________________ Signature: ____________ Date: - ________

Note: this is a triplicate form

 1st sheet is the User File copy
 2nd sheet is the Maintenance Progress File copy
 3rd sheet is the Equipment History File copy

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