Medical Device Verification and Validation Checklist
Use this form to document device identification, verification and validation checks, test conditions, results, and reviewer confirmation for a medical device.
Device and Test Identification
Device Name / Model
*
Device or Asset Identifier
*
Version or Revision Number
*
Test Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Test Conditions and Results
Test environment or conditions
*
Acceptance criteria met?
*
Yes
No
Observed results summary
*
Deviations or failures discovered
Reviewer Confirmation
Reviewer Name
*
First Name
Middle Name
Last Name
Submit
Should be Empty: