Engineer's Name : ID :

District :

Clinic Name :

KEW.PA No :

Purchase Date :

BREAKDOWN REPORT (BR)

BE Name : Manufacturer : CWO No :

BE No : Brand : CWO Date

User's Name : Model : MRE No :

User's Contact : S/N : PR No :

Problem Reported :

Problem Observed :

Root Cause Finding:

Date Engineer's Action

Date Specialist/ Cicle Incharge's Justification Name

Material Required :
STOCK CODE STOCK DESCRIPTION QTY STOCK CODE STOCK DESCRIPTION QTY

Plate Photo Equipment Photo Spares Photo

Attached YES Attached YES Attached YES