ANNEX – I

A.O. 2012-0012

Name of Health Facility

Complete Address

MAINTENANCE and MONITORING of PHYSICALFACILITY

BUILDING

No. of Period Location in the

Area Problem Encountered Action Taken
Items Covered Hospital
ex. Ceiling

ex. Ground ex. Damage due to water or

ex. 1x Monthly ex. Request for repair
Floor: Lobby sewage leaks

Prepared by ____________________________________
Signature over printed name

Date ____________________________________
DOH A02012-0012 Annex I Maintenance Physical Facility
Revision:00
01/20/2015
Page 1 of 3
 ANNEX – I
A.O. 2012-0012

Name of Health Facility

Complete Address

MAINTENANCE and MONITORING of PHYSICAL FACILITY

MECHANICAL

No. of Period Location in the

Item Problem Encountered Action Taken
Items Covered Hospital
ex. Air condition

ex. Monthly ex. Ground Floor ex. Worn-out air filter ex. Request replacement

Prepared by ____________________________________
Signature over printed name
DOH A02012-0012 Annex I Maintenance Physical Facility
Date ____________________________________ Revision:00
01/20/2015
Page 2 of 3
 ANNEX – I
A.O. 2012-0012

Name of Health Facility

Complete Address

MAINTENANCE and MONITORING of PHYSICAL FACILITY

ELECTRICAL

No. of Period Location in the

Item Problem Encountered Action Taken
Items Covered Hospital
Convenience
Outlets
ex.

ex. 2x weekly ex. Ground Floor ex. Missing cover ex. Request replacement

Prepared by ____________________________________
Signature over printed name

Date ____________________________________ DOH A02012-0012 Annex I Maintenance Physical Facility

Revision:00
01/20/2015
Page 3 of 3