HOSPITAL TUNKU AZIZAH

KUALA LUMPUR
SERVICE WORK (UNSCHEDULED & OTHERS)
FEMS
Request No. MWRWAC/F/2022/008622 Request Date/ Time 30-Aug-2022 11:19:00 AM
A.Requestor Details
SANGKARAO A/L
Requested By Designation Jurutera J41 Contact No. 0192866306
KUMARANAIDU
Category Breakdown Workgroup Civil Priority Critical
Asset No WACL3HEU004 Asset Name General Office
Serial No. Area Name Health Education Unit
Location Code L3-HEU-004 Location Name General Office
Brand/ Model 99001-NA Manufacturer 390117 - Not Applicable
Request Details I - AIR MENYUSUP MASUK KE DINDING - WG:CIVIL
B.Assessment Details
☐ Equipment is decontaminated and maintainence staff is informed of any potential hazard on the equipment
Assessment Details AIR MENYUSUP MASUK KE DINDING
MOHAMAD ZARIL HAKIM
Assessed By (AMS) Verified By (MoH)
BIN MOHD RAZALI
Signature Signature
Date & Time 30-Aug-2022 12:00:00 Date & Time
Asset Working Status ☐ Functioning ☐ Not Functioning ☐ Partially Functioning Loaner Provided ☐ Yes ☐ No

C.Part Details
No. Part No Description Qty

D.Employee Details
No. Staff ID Name Task No Date Start Date/ Time End Date/ Time Repair Hours

E. Process Status
☐ Propose for BER ☐ Propose for RW ☐ Equipment In Use ☐ Technical Advise ☐ Equipment not at Location
☐ Loaner Provision ☐ Alternate Service
Asset Remarks
F.Transmittal Details
Collected By (AMS) Witnessed By (MoH)
Signature Signature
Date & Time Date & Time
Remarks
G. Loaner Details
Loaner Asset No. Asset Name
Loaner Start Date/ Time Loaner End Date/ Time
Loaner Provided By (AMS) Loaner Received By (AMS)
Loaner Received By (MoH) Loaner Returned By (MoH)
H. Completion
Performance Test ☐ Done ☐ Not Applicable ☐ Not Done Electrical Safety Test ☐ Done ☐ Not Applicable ☐ Not Done
Date/ Time Work
Date/ Time Work Start DownTime hours
Completed
Action Taken
QC Code
Completed By (AMS) Verified By (MoH)
Signature Signature
Date & Time Date & Time
1st Verification Performed By 2nd Verification Performed By
Signature Signature
Name Name
Date Date