………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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Equipment Status Report‫تقرير حالة الجهاز‬

Department Unit/Room

Equipment S.N.

Model Vendor

Equipment ID Agent

Equipment (Request) Day Month Year Hour Min AM/PM

Received on:
The status of the above-mentioned equipment is as follows:
Code Status Party Done/To Do Day Month Year
01 Under repair/ Expected delivery date
Inspection
02 Sent for Repair Date Equipment Sent
03 Waiting for Date quotations
quotation requested
04 Waiting for Date received by
Support Support
05 Requires Expected date to finish
calibration calibration
06 Ordered spare Date of ordering spare
parts - waiting parts
07 Repaired Expected delivery date

08 Cannot repair –
will scrap
Name Signature
Written by:
Position
code/date
Received by:

Position/
Date
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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Equipment Scrapping Report ‫تقرير تكهين األجهزة‬

Department Unit/Room
Equipment S.N.
Model Vendor
Equipment ID Agent

Date of request of Day Month Year Hour Min AM/PM

scrapping
The above-mentioned equipment is to be scrapped because:
Code Reason for scrapping Details
01 Equipment is too old.

02 Equipment is damaged beyond repair.

03 Equipment technology is obsolete.

04 Equipment is unsafe (hazardous).

05 It is not economical to repair the equipment.

06 Needed spare parts/accessories cannot be

located.
07 Missing essential parts.

Name Signature
Written by:
Position &
code
* Spare Parts/Accessories
Part No. (1) Part No. (2)
Part Name Part Name
Approx Cost Approx Cost
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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Equipment Damage Report ‫تقرير إهالك لألجهزة‬

Department Unit/Room

Equipment S.N.
Model Vendor

Equipment ID Agent

Date equipment DD MM YY Date equipment DD MM YY

purchased damaged
Cause of Damage
Code How equipment was damaged Details
Describe Where?

01 Equipment fell from height.

02 Something fell on equipment.

03 Electric spike/over-
voltage/reverse of polarity
04 Equipment was overloaded.

05 Equipment is contaminated /
infected.
06 Feed flow/pressure/water/air/
ambient temperature.
07 Short-circuit

08 Attempt to repair has destroyed

sensitive parts.
09 Unknown/Other
Name Signature
Written by:
Position &
code
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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Equipment Feasibility Analysis Report‫تقرير تحليل دراسة جدوى‬

Department Unit/Room

Equipment S.N.

Model Vendor

Equipment ID Agent

Date equipment DD MM YY Today's date DD MM YY

purchased
(a) Equipment value when
purchased
(b) Equipment value now

(c) Cost of current repair

(d) Cumulative cost of repair

(obtained from history report)
(e) Number of years of operation

(f) % advantage of new technology

(compared to old one)
(g) Equipment rating (1 to 4, 1
being lowest)
(h) Replacement Factor (1 = sure
replacement)
Name Signature
Written by:

Position &
code

Rank 1 2 3 4

Improves Q of
Meaning: Nice to have Brings income Vital to life
patient care
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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Equipment History Report‫تقرير تاريخي للجهاز‬

Department Unit/Room

Equipment S.N.
Model Vendor
Equipment ID Agent Tel Fax

Equipment Purchasing Equipment Purchasing

Price: Date:

SR Date Action Taken Cost

DD MM YY PPM REP CAL SPR CUR CUM
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Name Signature
Reviewed by:

Position & code

PPM=Planned Preventive Maintenance, REP=Repair, CAL=Calibration, SPR=Spare Parts, CUR=Current cost, CUM=Cumulative Cost
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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‫تقرير تقييم الصيانة‬

M A I N T E N A N C E E V A L U A T I O N R E P O R T
Hospital: Department:

A . M a n a g e m e n t
Subcategories Evaluation Criteria TP of SC % Score
Yes No Explain/Rate
1 Is there a written Vision
statement?
2 Is there a written mission
statement?
3 Are there written objectives?

4 Is there a PPM program?

5 Is there an adequate stock of

supplies?
6 Is there an adequate stock of
spares?
7 Is there an internal evaluation?

8 Is there an emergency mgmt

plan?
B . P e o p l e ( A v e r a g e / C o l l e c t i v e )
Subcategories Evaluation Criteria TP of SC % Score
Evaluation Explanation
1 Staff Uniform
(Fair/Good/Not there)
2 Staff Nametags
(Yes/No)
3 Staff Training
(None/Poor/Fair/Good/Excellent)
4 Staff qualifications
(Poor/Fair/Good/Excellent)
5 Staff abilities (Hands-on)
(Poor/Fair/Good/Excellent)
6 Staff number is adequate?
(None/Very Low/Low/Adequate)
7 Staff relations with others
(Poor/Fair/Good/Excellent)
8 Patient satisfaction index
(Unsatisfied/Sat/Highly Satisfied)
C . E q u i p m e n t ( M o s t I m p o r t a n t 3 p e r R o o m )
Category Equipment 1 Equipment 2 Equipment 3 TP of SC % Score
1 Name/
Manufacturer
2 ID Code/ SN

3 Model
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

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4 Years in
Operation
5 Mean Time
Between F
6 % Annual
Downtime
7 General
Condition
Score

D . D o c u m e n t a t i o n ( A l l )
Subcategories Evaluation Criteria TP of SC % Score
Evaluation Explanation
1 Accessibility
(Easily Accessible/Difficult)
2 Completeness
(Incomplete/Complete)
3 Backlog
(> 6 months /3-6/<3/No backlog)
4 Data Accuracy
(Inaccurate/Somewhat/Accurate)
E . F i n a n c i a l ( A l l E q u i p m e n t ) ُ
1 Annual contracts cost (LE)
(All contracts, lump sum)
2 Annual labor cost
(In-house Engineering Staff)
3 Annual consumables cost
(All consumables)
4 Annual spare parts cost
(All Spare parts)
5 Annual Total Costs (LE)
(Add 1 through 4 Above)
6 Annual % Maintenance Costs
(From current equipment value)
F . S a f e t y / E n v i r o n m e n t
1 Compliance with radiation
safety (Compliant/Non)
2 Electrical safety Procedures
(Not Available/Available)
3 Electrical Safety Tests (actual)
(None/One/Two/Three/All 4)
4 Ventilation adequacy
(Inadequate/Adequate)
5 Air conditioning
(Deviation from Optimal Point)
6 Overall Department Tidiness
(Poor/Fair/Good/Excellent)
5 Warning Signs
(None/Some/All)

TP of SC: Total Points of Subcategory % of Overall: calculated as TP of Category/TP of Evaluation

………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

……………………… : ‫التاريخ‬
…………………………:‫المرفقات‬

I n s t a l l a t i o n R e p o r t
DD MM YY DEPT
DATE
PHONE FAX
AGENT
PHONE FAX
MANUFACTURER
FLOOR ROOM A/C ELEC SPACE LIGHTS
LOCATION/
ENVIRONMENT
SERIAL NUMBER MODEL NUMBER ID CODE
EQUIPMENT

T E S T S
Status SPECIFY
FUNCTIONS
ALARMS
SAFETY
QA/QC
D E L I V E R A B L E S
DESCRIPTION QTY CONDITION

ACCESSORIES

Service
MANUALS
Operation
Software

SPARE PARTS

C O M M E N T S

P E R S O N N E L
NAME SIGNITURE

CO. ENGINEER

HOSPITAL REP

OTHERS
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

……………………… : ‫التاريخ‬
…………………………:‫المرفقات‬

‫تقرير الصيانة الدورية المخططة‬

D a i l y P P M R e p o r t
DD MM YY
DATE DEPT
PHONE FAX
AGENT
PHONE FAX
MANUFACTURER
LOCATION/ FLOOR ROOM A/C ELEC SPACE LIGHTS
ENVIRONMENT
SERIAL NUMBER MODEL NUMBER ID CODE
EQUIPMENT

Month:
Procedures Person/
CLN POST FNC PHYS ALRM INSP Signature
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
31
CLN: Clean Exterior (All) POST: Power-on self test FNC: All Functions. PHYS: Physical Condition ALRM: All alarms INSP: Inspect all
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

……………………… : ‫التاريخ‬
…………………………:‫المرفقات‬

S e m i - A n n u a l P P M R e p o r t
F o r X - R a y M a c h i n e s
HOSPITAL GOV

DATE DD MM YY DEPT

AGENT PHONE FAX

MANUFACTURER PHONE FAX

LOCATION/ FLOOR ROOM A/C ELEC SPACE LIGHTS

ENVIRONMENT

EQUIPMENT SERIAL NUMBER MODEL NUMBER ID CODE

C O N T R O L U N I T H T G E N E R A T O R
Control functions KVp, mA (min):
Alarms KVp, mA (max):
Labels KVp, mA (average):
Lamps/Buttons/keyboards Cables:
Fuses Physical Condition:
X - R A Y T U B E X - R A Y T A B L E
Tube Hanger Mechanism: Limit Switches:
Oil Leaks: Movements:
Anode Rotor: Bucky:
D O C U M E N T A T I O N
Equipment Label: Job Dates Clarity ID Code
Data Trend: No Trends Slight Trends (+/-) Strong Trends (+/-)
Operator Docs: Updated Slightly delayed Major Delays
Catalogs: Complete Missing
S T O C K L E V E L
Part < Safe > Safe Supply < Safe > Safe Level
Level Level Level

E N V I R O N M E N T
Mains Power Fluctuations: Over voltage Under voltage Spikes Blackout
Mains Power Phases: OK Reversed 2-phase
Lighting: OK Dim
Ambient Temp:
P E R S O N N E L
NAME SIGNITURE
ENGINEER
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

……………………… : ‫التاريخ‬
…………………………:‫المرفقات‬

A n n u a l P P M R e p o r t
F o r X - R a y M a c h i n e s
HOSPITAL GOV

DATE DD MM YY DEPT

AGENT PHONE FAX

MANUFACTURER PHONE FAX

LOCATION/ FLOOR ROOM A/C ELEC SPACE LIGHTS

ENVIRONMENT
EQUIPMENT SERIAL NUMBER MODEL NUMBER ID CODE

C O N T R O L U N I T H T G E N E R A T O R
Internal Cleaning: Oil level (if applicable):
Control functions: KVp, mA (min):
Alarms: KVp, mA (max):
Timer circuit accuracy: KVp, mA (average):
Lamps/Buttons/keyboards: Cables:
Fuses Physical Condition:
X - R A Y T U B E X - R A Y T A B L E
Collimator Alignment: Limit Switches:
Spot film device: Bearings:
Auto Brightness Control: Alignments:
Automatic Exposure Control: Motor (if exists):
Shutter: Paint/Surface finish:
Focal Spot: Movements:
Anode Rotor: Bucky:
D O C U M E N T A T I O N
Equipment Label: Job dates Clarity ID Code
Data Trend: No Trends Slight Trends (+/-) Strong Trends (+/-)
Operator Docs: Updated Slightly delayed Major Delays
Catalogs: Complete Missing
P A R T S / S U P P L I E S C H A N G E D
Part Part Qty Supply Stock Qty
Description Number Description Number

Page 1 of 2
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

……………………… : ‫التاريخ‬
…………………………:‫المرفقات‬

S T O C K L E V E L
Part < Safe > Safe Supply < Safe > Safe Level
Level Level Level

E L E C T R I C A L S A E T Y
Actual Action After
Protective Earth Continuity Test:
Insulation Test:
Earth Leakage Current Test:
Enclosure Leakage Current Test:
F U R T H E R C O M M E N T S

P E R S O N N E L
NAME SIGNITURE
Co.
Engineer
Hospital
Engineer

Page 2 of 2
………………………… : ‫الرقـم‬ ‫بسم هللا الرحمن الرحيم‬ ‫الجمهورية اليمنية‬

……………………… : ‫التاريخ‬
…………………………:‫المرفقات‬

Equipment Repair Request‫طلب إصالح جهاز‬

Department Unit/Ro
om
Equipment S.N.

Model Vendor

Equipment ID Agent Tel Fax

Equipment Installation Equipment Priority

date Code
The above-mentioned equipment has failed with the following details:
Code Brief Description of Problem Details
01 Equipment totally dead
02 Equipment works but with defects
03 Equipment works on and off
04 Noisy operation
05 Equipment requires supplies
06 Software problem
07 Inaccurate Results
08 Equipment is missing parts
09 Equipment is broken/damaged
10 Other (Please specify)

Please write any further complaints or comments:

Name Signature Date

Submitted by
Received by