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Request for a service

Request for repair and maintenance of medical equipment

Facillity name

DistrictAdjumaniAruaKobokoLuweroMadi-OkolloMarachaMoyoNakasekeNakasongolaNebbiObongiPakwachTeregoYumbeZombo

Reporter Name

Reporter roleMedical OfficerNurseBiomedical TechnicianBiomedical EngineerFacility AdministratorOther (please specify)

Reporter Role (If Other)

Phone

Email

Equipment NameOxygen ConcentratorOxygen CylinderO2 CubePulse OximeterNebulizerVentilatorSuction MachineDefibrillatormOther (please specify)

Equipment Name (If unlisted)

Equipment StatusFunctional but needs maintenanceNot functionalPartially functionalUnknown

Description of the Issue

Urgency of RequestHigh (affecting patient care)Medium (needs repair soon)Low (routine maintenance)

Date of Last Maintenance

Comments or Additional Information

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