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    Equipment Assessment Report Form

    Uploaded by

    Chala Dabala

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Equipment Assessment Report Form

    Uploaded by

    Chala Dabala
    28 views1 page

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    28 views1 page

    Equipment Assessment Report Form

    Uploaded by

    Chala Dabala

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Facility Name____________________________________________________________________ Assessment date ___________________

    Equipment Name Model Serial Number Status Identified Problems Actions Needed Parts Needed Remarks
    1. a. ________________ a. ________________ a. ________________
    b. ________________ b. ________________ b. ________________
    c. ________________ c. ________________ c. ________________
    a. ________________ a. ________________ a. ________________
    2. a. ________________ a. ________________ a. ________________
    b. ________________ b. ________________ b. ________________
    c. ________________ c. ________________ c. ________________
    a. ________________ a. ________________ a. ________________
    3. a. ________________ a. ________________ d. ________________
    b. ________________ b. ________________ e. ________________
    c. ________________ c. ________________ f. ________________
    a. ________________ a. ________________ a. ________________
    4. a. ________________ a. ________________ a. ________________
    b. ________________ b. ________________ b. ________________
    c. ________________ c. ________________ c. ________________
    d. ________________ d. ________________ d. ________________
    Accessor1. ____________________________ Signature: ______ Accessor2. ____________________________ Signature: ______
    Accessor3. ____________________________ Signature: ______ Accessor4. ____________________________ Signature: ______

    Facility Representative Name_________________________________ Sign __________ Date________________


    Facility Official Stamp

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