ICMS CAMP

BATTERY-OPERATED SMOKE DETECTOR MAINTENANCE LOG FOR (Year): ______

All battery-operated smoke detectors present in the facility are required to be tested and maintained in
accordance with manufacturer’s instructions. This form is to be used to record the dates on which these
detectors are tested and cleaned and batteries replaced. Any problems found must be noted in the “Comments”
section of this form. Each entry must be initialed by the person performing the service.
T = Tested C = Cleaned
Date Battery
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Replaced
Date

Location:

Comments: ________________________________________________________________________
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ANY TOWN NURSING HOME

F OHSMS 19
 BATTERY-OPERATED SMOKE DETECTOR MAINTENANCE LOG FOR: 2008

All battery-operated smoke detectors present in the facility are required to be tested and maintained in
accordance with manufacturer’s instructions. This form is to be used to record the dates on which these
detectors are tested and cleaned and batteries replaced. Any problems found must be noted in the “Comments”
section of this form. Each entry must be initialed by the person performing the service.
T = Tested C = Cleaned
Date Battery
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Replaced
Date 1/12 2/11 3/13 4/11 5/11 6/10

T/C T T T T T 6/10/08
Location: Room 110 JJL JJL JJL JJL JJL JJL JJS

T T/C T T T T
Room 111 JJL JJL JJL JJL JJL JJL

T T T/C T T T
Room 112 JJL JJL JJL JJL JJL JJL

T/C T T T T T 6/30/08
Room 210 RLI RLI RLI RLI RLI RLI JJS

T T/C T T T T 6/30/08
Room 211 RLI RLI RLI RLI RLI RLI JJS

T T T/C T T T
Room 212 RLI RLI RLI RLI RLI RLI

Comments: Smoke detector in Room 110 was found damaged on 6/10/08 and was replaced that date
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January 2, 2009

F OHSMS 19