PLANNED PREVENTIVE MAINTENANCE Rumah Sakit Umum

Daerah Kota Mataram

Improvement Maintenance Measure
Equipment : Incubator LAB N. Internal :
Sub-Unit : LABORATORIUM Inventory No :
Brand : MEMERT Division : LABORATORIUM
Model /Type : INE 400 Building : GEDUNG A
Serial N. : C4130630 Room : BDRS
M.M.I. *) : PM Interval : 3 months = 12 weeks
Year : 2012
CHECK LIST
1 2 3 4
VISUAL CHECK OK Not
OK
OK Not
OK
OK Not
OK
OK Not
OK

1. Cek kondisi fisik alat dari kerusakan        

2. Cek kabel power dan koneksi        

3. Cek tombol on-off dan fuse power        

4. Cek semua accessories dalam kondisi baik        

SAFETY CHECK
6. Cek tahanan ground dan koneksi elektrik lain **)        

7. Cek kebocoran arus ground pada kondisi normal **)        

MAINTENANCE
8. Bersihkan unit dari kotoran        

9. Cek suhu        

10 Cek tampilan LCD        

11. Cek keypad        

12.        

13.        

14.        

15.        

16.        

17. Lakukan uji fungsi alat        

Penghitungan jam kerja alat : ……. jam ……. jam ……. jam …… jam

PERFORM DATE
EXECUTION TIME
(PPM STANDARD TIME Hrs.)
TECHNICIAN NAME AND SIGNATURE
USER NAME AND SIGNATURE

Remarks :
 *) To complete the routine inspection with Operation Manual and Manufacture Manual Instruction (MMI) , if it is required.
 To check the inventory number and replace the label if is necessary..
 Always complete all the information.
 **) See: Electrical Safety Evaluation

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 ELECTRICAL SAFETY EVALUATION
(For equipment class I)
No
Measure step Norm Measure
unity 1 2 3 4
1 Mains Voltage 22010% Volts
2 Power -----* VA
3 Ground Leakage Current ≤ 500 µA
3.1 Single fault condition (Open feed line) ≤ 1000 µA
4 Enclosure leakage current ≤ 100 µA
4.1 Single fault condition (open feed line) ≤ 500 µA
4.2 Second fault condition (open ground line) ≤ 500 µA
5 Insulated Resistance between line 2 M
conductors to ground
6 Ground Resistance ≤ 0.2 
* In the equipment evaluation it must not exceed a consume power of 3.5KW.

Changeable Material Minimum Spare parts Tools and Measuring Equipments

Surface cleaner Fuse Multimeter

Contact cleaner Standard Service Tools
Flannel / tissue Electrical Safety Analyzer/
Grease Portable Vacuum Cleaner

OBSERVATIONS

1.

2.

RECOMMENDATION 1 2 3 4
The equipment has no problems. Result of safety test showed no deviation from
the required reference values    
The equipment has minor problems that do restrict its use. However they should
be corrected as the preventive measure. Result of safety test showed no deviation    
from the required reference values
The equipment has major problems. For safety reasons, the equipment may not be
used until the problem has been resolved.    

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