Medical Equipment Performance Assessment
Evaluate the operational status and performance of medical equipment in your healthcare facility.
Equipment Information
Provide details about the medical equipment being assessed.
Equipment Name/Type
*
Manufacturer/Brand
Model Number
Serial Number / Asset ID
*
Equipment Location (Department/Room)
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Full Name
*
First Name
Last Name
Assessment Criteria
*
Rows
Excellent
Good
Fair
Poor
Power Functionality
1
2
3
4
Display/Indicators
5
6
7
8
Calibration Status
9
10
11
12
Physical Condition
13
14
15
16
Safety Alarms
17
18
19
20
Accessories Present
21
22
23
24
Cleanliness/Sterilization
25
26
27
28
Is the equipment functioning as intended?
*
Yes
No
Does the equipment require immediate maintenance or repair?
*
Yes
No
Checklist: Select all that apply
User manual available
Maintenance log updated
Calibration certificate present
Warning labels intact
Other (please specify)
Overall Equipment Condition
*
1
2
3
4
5
Assessor Comments / Recommendations
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