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                                                                                            INVENTORY CONTROL

                                         MAINTENANCE OF EQUIPMENT NOTICE - IC 9

DATE: _____/_____/_____

DEPARTMENT: _____________________________________________________________________

HEALTH CENTER TAG NUMBER (S) : ______ ______ ______ ______ ______ ______ ______

DESCRIPTION: _____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

MAINTENANCE SCHEDULE:

1. Performed by: ____________________________________________________________________

2. Interval of Maintenance: ___________________________________________________________

3. Date of last maintenance routine: _____ /_____ /_____

Performed by: ___________________________________________________________________

EXPLANATION OF MAJOR REPAIRS:

1. Description: _____________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

2. Purchase Order Number: __________________________________________________________

3. Repair Amount: _____________ 4. Acquisition Cost: _______________

PREPARED BY: ___________________________________________________ ___/___/___                              
                               Custodial Person                                                                                                Date

IMPORTANT NOTICES TO DEPARTMENT HEAD:

  1. YOUR SIGNATURE ALSO CONFIRMS THAT ALL EQUIPMENT & ACCESSORIES USED WITH/OR HAVING CONTAINED RADIOACTIVE OR OTHER HAZARDOUS MATERIALS HAVE BEEN INSPECTED & APPROVED FOR SHIPPING AND/OR STORAGE BY ENVIRONMENTAL & RADIATION SAFETY.
     

  2. YOUR SIGNATURE ALSO CONFIRMS THAT ALL ELECTRONIC STORAGE EQUIPMENT & DEVICES HAVE BEEN PROPERLY CLEANED OF INFORMATION ACCORDING TO UCHC HIPAA POLICIES.

APPROVED BY:

___________________________________________________ _____/_____/_____

Department Head Date

___________________________________________________ _____/_____/_____

Financial Officer Date

___________________________________________________ _____/_____/_____

Inventory Control Date