CHECK LIST PEMERIKSAAN FASILITAS FISIK

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Hal. 1 dari 2
NO. URAIAN HASIL PEMERIKSAAAN KETERANGAN PEMERIKSA
A. BANGUNAN GEDUNG :
A.1 Struktur Tanah Sekeliling Gedung Stabil { } Tdk Mengalami Penurunan { }
A.2 Tiang / Kolom Penyanggah Gedung Stabil { } Tdk Mengalami Penurunan / Retak { }
A.3 Dinding / Tembok Luar Gedung Kuat { } Tdk Retak { } Cat Tdk Luntur { }
A.4 Atap Gedung Kuat { } Tdk Bocor { } Kemiringan Cukup { }
A.5 Dinding / Tembok Dalam Gedung Kuat { } Tdk Retak { } Cat Terang / Tdk Kotor { }
A.6 Plafon Rangka Kuat { } Tdk Berjamur { } Tdk Kotor { }
A.7 Lantai Kuat { } Kedap Air { } Mudah Dibersihkan { }
A.8 Tangga Naik / Turun Kuat { } Aman { } Mudah Dilewati { }
A.9 Pintu Masuk & Keluar Gedung Kuat / Aman { } Cukup Tinggi / Lebar { }
A.10 Pintu Darurat Mudah Dilihat{ } Ada Petunjuk { } Selalu Tertutup { }
A.11 Tangga Darurat Aman Dilewati { } Tdk Ada Barang Penghalang { }

B. INSTALASI ELEKTRIKAL :
B.1 Panel TM Berfungsi Normal ( ) Sistem Proteksi Ada ( )
B.2 Trafo Berfungsi Normal ( ) Oli Trafo Msh Baik ( )
B.3 Panel LVMDP Berfungsi Normal ( ) ACB Bekerja normal ( )
B.4 Genset Berfungsi Normal ( ) Kondisi Battery/Accu Baik ( )
B.5 Panel Genset Berfungsi Normal ( ) Standby Auto ( )

C. INSTALASI MEKANIKAL :
C.1 Pompa Air Bersih Berfungsi { } Otomatis { } Ada Pompa Cadangan { }
C.2 Pipa Air Bersih Tdk Bocor { } Tdk Berkarat { } Cat Terang { }
C.3 Pompa Air Panas Berfungsi { } Otomatis { } Ada Pompa Cadangan { }
C.4 Pipa Air Panas Tdk Bocor { } Tdk Berkarat { } Cat Terang { }
C.5 Jockey Pump Berfungsi Normal ( )
C.6 Electric Pump Berfungsi Normal ( )
C.7 Tangki Solar Utama Tdk Bocor { } Pompa solar berfungsi { }
C.8 Ground Tank Air Bersih Tertutup { } Bersih { } Meteran PDAM Berfungsi { }
C.9 Boiler Air Panas Berfungsi { } Otomatis { } Ada Boiler Cadangan { }
C.10 Reservoir Atas Tertutup { } Bersih { } Ada Alat Monitor Level Air { }
C.11 Lift Berfungsi Normal ( ) ARD Berfungsi Baik { }
C.12 Tangga Darurat Fan Berfungsi Normal { }
 Hal. 2 dari 2
NO. URAIAN HASIL PEMERIKSAAAN KETERANGAN PEMERIKSA
D. SISTEM TELEKOMUNIKASI
D.1 PABX Berfungsi Normal ( )
D.2 Meja Console Operator Berfungsi Normal ( )
D.3 MATV Berfungsi Normal ( ) Penerimaan Indovision Baik { }
D.4 Car Call / Paging Berfungsi Normal ( )
D.5 Nurse Call Berfungsi Normal ( )

E. RUANGAN
E.1 Ruang OK Suhu memenuhi { } Tekanan Positif { }
E.2 Ruang Isolasi Tekanan Negatif { }

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