Medical Device Access Management Checklist
Use this checklist to request, review, and approve access to medical devices, including the device details, access scope, scheduling, and required training or approval notes.
Requester and Access Need
Requester Full Name
*
First Name
Middle Name
Last Name
Department / Unit
*
Please Select
Radiology
Surgery
ICU
Emergency
Anesthesia
Biomedical Engineering
Nursing
Other
Role / Job Title
*
Email Address
example@example.com
Reason for Device Access
*
Needed-By Date
*
-
Month
-
Day
Year
Date
Medical Device Details
Medical Device Name
*
Device Category / Type
*
Diagnostic
Monitoring
Therapeutic
Imaging
Surgical
Laboratory
Other
Device ID or Asset Tag
Location / Site Where Access Is Needed
*
Access Area / Department
*
Please Select
Radiology
ICU
Operating Room
Emergency Department
Laboratory
Patient Monitoring Unit
Sterile Processing
Other
Access Scope and Conditions
Access level needed
*
View-only
Temporary use
Routine access
Emergency access
Maintenance/support access
Access start date and time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Access end date and time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Supervision requirement
*
No supervision required
Supervised at all times
Supervised for initial access only
Case-by-case supervision
After-hours access needed
*
No
Yes
Restrictions or notes
Training and Approval Checklist
Required training completed?
*
Yes
No
Training completion date
-
Month
-
Day
Year
Date
Supervisor/approver name
*
Approval status
*
Please Select
Pending
Approved
Denied
Approval notes or conditions
Submit Checklist
Should be Empty: