Medical Imaging Equipment Maintenance Plan Checklist Form
Complete this form to document the maintenance and inspection of medical imaging equipment. Ensure all checklist items are reviewed and actions recorded.
Equipment Type
*
Please Select
X-ray Machine
MRI Scanner
CT Scanner
Ultrasound Machine
PET Scanner
Other
Equipment Serial/Asset Number
*
Maintenance Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Performed By (Staff Name)
*
Checklist: Power Supply and Connections
*
OK
Needs Attention
N/A
Checklist: Image Quality Assessment
*
OK
Needs Attention
N/A
Checklist: Safety Interlocks & Alarms
*
OK
Needs Attention
N/A
Issues Identified (if any)
Corrective Actions Taken
Maintenance Completion Confirmation
*
Completed
Partially Completed
Not Completed
Submit Checklist
Should be Empty: