General Hospital Information

Hospital/Clinic Name

Photo of Hospital/Clinic
Address

Phone No.

Doctors Name

Doctors Email

Head Nurses Name

Head Nurses Email

Technician/s

Technicians email

Number of Patients

Number of Dialysis Stations

Number of ICU Points

WATER TREATMENT

WTS SPECIFICATIONS

Raw water tank/s and booster pump/s

Add media

Sand/Media Filter-Size-Valve Type- Backwash Flowrate

Sand/Media Filter

Water Softener-Brine Tank Setup

Water Softener & Brine Assembly

Carbon Filtration

Does the Carbon Filter meet the required EBCT
Carbon Filters

Cartridge Filtration

Cartridge Filter

Brand of Reverse Osmosis System/Manufacturer

Model I.e. How many membranes? Output of System? Year of Installation?

Does the Reverse Osmosis Meet ISO 26722

Reverse Osmosis System Photo

General comments on Reverse Osmosis System

Bypass

General Comments of Bypass Arrangement

Bypass Photos

Distribution System type

Loop Material
Loop Size
Approximate Loop Length
Loop & Outlet Points

General Comments of Loop & Outlet Points

General Comments of WTS Equipment

Reverse Osmosis Tank

Reverse Osmosis Tank (ROT)

Brand/Manufacturer

Size of Tank in Litres

Photo of ROT

General Comments of ROT

PORTABLE RO

PORTABLE RO

Number - Make - Model - Age

Photos of Portable WTS Equipment

General Comments on Portable WTS Equipment

Reprocessor

Reprocessor Equipment

Number-Make-Model-Age

Photo of Reprocessing Equipment

General Comments of Reprocessing Equipment

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.