Clinical Engineering - PC/Printer - IT'S: Break/Fix form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Summery: Below is the information needed before calling the CBIS Desktop/ IT bridge line at 4-4431

Requestor

• Clients Full Name

• Request or Phone # or Pager

Problem

• Problem Description

• Application Information

• Screenshot / Photo

  Media

Location Information

• Room#

• Room Type

Clinical Engineering

• Integrated

• Patient TV issue

• Nurse Call

• Anesthesia Device

Computer / R2 Information

• Computer Name

• IP Address

• Device Tag

• Device Type

  computer

  R2

Printer Information

• Printer Name

• Printer Type

• Device Asset Tag

ITS

• Phone Type

  Wireless

  Desktop

  Wall

  Red Phone

• Phone Number

• Model Number (non Red Phone)

• Network Jack#

• Fax/MFD: Location

• Other: Device Type, Location, Jack

SDE Ticket Information

• Ticket Type

• Urgency

  High

  Medium

  Low

• Impact

  High

  Medium

  Low

• SDE Group Assigned To