Ruangan/

Complaint Penanganan Pelapor Petugas Nama & No. Alat

Unit
Waktu
Hari/Tgl Waktu Hari/Tgl
Start Selesai

I. FORMULIR SERVICE
Kerusakan :
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Perbaikan :  Tenaga Umum IPSRS Kondisi :  Baik  Kurang Baik

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Analisa :  Tenaga Ahli

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Tindakan : Kondisi :  Baik  Kurang Baik

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 Ruangan/
Complaint Penanganan Pelapor Petugas Nama & No. Alat
Unit
Waktu
Hari/Tgl Waktu Hari/Tgl
Start Selesai

II. FORMULIR SERVICE PENARIKAN ALAT

Alasan Penarikan :
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III. FORMULIR USULAN PENGADAAN
 Sparepart  Alat Baru
Nama / Jenis Barang Merk / Tipe / Spesifikasi Jumlah Permintaan

Mengetahui,
Kepala Tenaga Ahli Koordinator
Unit/Petugas UPSRS

(___________________) (___________________) (___________________)

 Formulir Pengontrolan Alat Medis Rumah Sakit

Bulan :
Hari/Tanggal :

No Instalasi/Unit Kondisi Alat Medis Keterangan

1 IGD

2 VK Siti Hajar

3 Vk Maryam

4 IBS/OK

5 Ruang Bayi

6 Ruang Perawatan Ibu Lantai II

7 Ruang Perawatan Ibu Lantai III

8 Poli Kandungan

9 Poli Anak

10 Poli Gigi

11 Poli Penyakit Dalam

12 CSSD

13 Ambulance

14 Kamar Jenazah