Medical Exam Light Inventory Form
Please complete this form to record and update inventory details for medical exam lights in your facility.
Asset Tag or Inventory Number
*
Manufacturer
*
Model Number
*
Serial Number
*
Location (Department/Room)
*
Date of Purchase/Installation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Condition
*
Operational
Needs Maintenance
Out of Service
Last Maintenance Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Responsible Staff Member
First Name
Last Name
Maintenance Performed
Bulb Replacement
Electrical Check
Cleaning
Other
Additional Notes
Submit Inventory
Should be Empty: