Title Page

  • Conducted on

  • Prepared by

  • Outside Temperature

  • Outside Humidity

Central Plant

Vacuum Pumps

  • Vacuum Pump #1

  • Vacuum Pump #2

  • Vacuum Pump #3

  • Vacuum Pump #4

  • Tank Vacuum HG

  • Tank Vacuum in range? (18-23 hg is standard range)

Heat Exchanger #1

  • HWP#1

  • HWP#2

  • Suction PSI

  • Suction PSI in range? (30-45 psi is standard range)

  • Discharge PSI

  • Discharge PSI in range? (45-65 psi is standard range)

  • Heating Water Supply Temperature

AHU #1 (Serving Materials Room)

  • AHU-1 Supply Air Fan

  • AHU-1 Return Air Fan

Control Air Compressor System 1 (near AHU#1)

  • Control Air Compressor #1

  • Control Air Compressor #2

  • Tank Pressure

  • Tank Pressure in range? (85-110 psi)

  • Oil Level Pump 1 (Monday Check)

  • Oil Level Pump 2 (Monday Check)

Condensate Pump

  • Condensate Pumps

  • Check Pump (Mondays)

Control Air Compressor System 2 (near Medical Air Compressor)

  • Control Air Compressor #1

  • Control Air Compressor #2

  • Tank Pressure

  • Tank Pressure in range? (140-160 psi)

  • Oil Level Pump 1 (Monday Check)

  • Oil Level Pump 2 (Monday Check)

Medical Air Compressor

  • Compressor #1

  • Compressor #2

  • Compressor #3

  • Medical Air Tank Pressure

  • Medical Air Tank Pressure in range? (80-100 psi)

  • Dewpoint

  • CO2

Medical Air Dryer

  • Dryer #1

  • Dryer #2

Domestic Water Booster Pumps

  • Domestic Water Booster Pump #1

  • Domestic Water Booster Pump #2

  • Domestic Water Booster Pump #3

  • Domestic Water Booster Pump Pressure

  • Domestic Water Booster Pump Pressure in range? (76-82 psi)

  • Domestic Water Booster Pump HZ

Domestic Water Heaters

  • Domestic Water Heater #3 (Serving Dish Machine)

  • Domestic Water Heater #3 Temperature
  • Domestic Water Heater #2 (Serving Main Building)

  • Domestic Water Heater #2 Temperature
  • Domestic Water Heater #1 (Serving Main Building)

  • Domestic Water Heater #1 Temperature

Fuel Oil Level

  • Boiler Room Fuel Oil Gallons (read at Veeder Root)

Boiler #3

  • Boiler #3 On/Off

  • Boiler #3 Lead/Lag

  • Boiler #3 Fuel

  • Boiler #3 Steam Pressure

  • Boiler #3 Steam Pressure in range? (60-90 psi)

  • Boiler #3 Stack Temp
  • Boiler #3 Water Level (Passing 3-7 green lights)

  • Boiler #3 Top Blow-Down

  • Boiler #3 Bottom Blow Down

Temporary Boiler

  • Temp. Boiler On/Off

  • Temp. Boiler Lead/Lag

  • Temp. Boiler Fuel

  • Temp. Boiler Steam Pressure

  • Temp. Boiler Steam Pressure in range? (60-90 psi)

  • Temp. Boiler Stack Temp
  • Temp. Boiler Water Level

  • Temp. Boiler Top Blow-Down

  • Temp. Boiler Bottom Blow Down

Dearator Tank

  • Check Salt Level

  • Left Side of DA Tank Temp (Lower Gauge)
  • Left Side of DA Tank Temp (Lower Gauge) in range? (200-220F)

  • Crossover Pump

  • Boiler Pump #1

  • Boiler Pump #2

  • Boiler Pump #3

  • Right Side of DA Tank Temp (Upper Gauge)
  • Right Side of DA Tank Temp (Upper Gauge) in range? (225-250F)

Nitrous Oxide Manifold

Nitrous Oxide Manifold Farm

  • Bank In Service

  • Bank In Service Pressure

  • Reserve Bank

  • Reserve Bank Pressure

  • Line Pressure

  • # of Full Cylinders on Hand

Dietary Mechanical Room (outside door by dumpster)

AHU 2 (serving Dietary)

  • AHU 2 Supply Air Fan

  • AHU 2 Supply Air Fan Drives

  • AHU 2 Return Air Fan

  • AHU 2 Return Air Fan Drives

Heat Exchanger #11

  • HWP #1

  • HWP #2

  • Suction PSI

  • Suction PSI in range? (15-30 psi)

  • Discharge PSI

  • Discharge PSI in range? (45-65 psi)

  • Heating Water Supply Temperature

Condensate Pumps

  • Condensate Pumps On/Off/Auto

  • Test Pump (Monday)

Med Gas/Air Farm

Oxygen & Nitrogen Farm Levels & Readings

  • Nitrogen Main Building Line Pressure

  • Nitrogen Main Building Tank Pressure

  • Nitrogen Reserve Tank Pressure

  • Nitrogen Assist Tank Pressure

  • Nitrogen Assist Line Pressure

  • Nitrogen Mini Bulk Level (inches)

  • O2 Bulk Main Tank Level (Large Tank) Inches of Water

  • O2 Bulk Main Tank Level (Large Tank) PSIG

  • O2 Bulk Reserve Tank Level (Small Tank) Inches of Water

  • O2 Bulk Reserve Tank Level (Small Tank) PSIG

Chiller Plant

Chiller #3 (by Generator Room)

  • Chiller #3 Status

  • Chiller #3 Full Load Amps %

  • Chiller #3 Operating Hours

  • Chiller #3 Evaporator Water Temp - Leaving Chiller #3 Evaporator Water Temp - Entering Chiller #3 Condenser Water Pump - Leaving Chiller #3 Condenser Water Pump - Entering
  • Chiller #3 Right Valve PSI

  • Chiller #3 Left Valve PSI

Chiller #2 (Middle)

  • Chiller #2 Status

  • Chiller #2 Full Load Amps %

  • Chiller #2 Operating Hours

  • Chiller #2 Evaporator Water Temp - Leaving Chiller #2 Evaporator Water Temp - Entering Chiller #2 Condenser Water Pump - Leaving Chiller #2 Condenser Water Pump - Entering
  • Chiller #2 Right Valve PSI

  • Chiller #2 Left Valve PSI

Chiller #1 (by wall)

  • Chiller #1 Status

  • Chiller #1 Full Load Amps %

  • Chiller #1 Operating Hours

  • Chiller #1 Evaporator Water Temp - Leaving Chiller #1 Evaporator Water Temp - Entering Chiller #1 Condenser Water Pump - Leaving Chiller #1 Condenser Water Pump - Entering
  • Chiller #1 Right Valve PSI

  • Chiller #1 Left Valve PSI

Refrigerant Alarm

  • PPM

  • Normal/Alarm

Cooling Tower #1 Filter

  • Cooling Tower #1 Filter - On/Off

  • Cooling Tower #1 Filter - Inlet PSIG

  • Cooling Tower #1 Filter - Inlet PSIG in range? (35-55 PSIG)

  • Cooling Tower #1 Filter - Outlet PSIG

  • Cooling Tower #1 Filter - Outlet PSIG in range? (25-40 PSIG)

  • Cooling Tower #1 Filter - Side Stream Filter

  • Clean Side Stream Filter (Thursday)

Cooling Tower #2 Filter

  • Cooling Tower #2 Filter - On/Off

  • Cooling Tower #2 Filter - Inlet PSIG

  • Cooling Tower #2 Filter - Inlet PSIG in range? (35-55 PSIG)

  • Cooling Tower #2 Filter - Outlet PSIG

  • Cooling Tower #2 Filter - Outlet PSIG in range? (25-40 PSIG)

  • Cooling Tower #2 Filter - Side Stream Filter

  • Clean Side Stream Filter (Thursday)

Cooling Tower #3 Filter

  • Cooling Tower #3 Filter - On/Off

  • Cooling Tower #3 Filter - Inlet PSIG

  • Cooling Tower #2 Filter - Inlet PSIG in range? (35-55 PSIG)

  • Cooling Tower #3 Filter - Outlet PSIG

  • Cooling Tower #2 Filter - Outlet PSIG in range? (25-40 PSIG)

  • Cooling Tower #3 Filter - Side Stream Filter

  • Clean Side Stream Filter (Thursday)

Cooling Tower Water Meter

  • Cooling Tower Water Meter Reading (Gallons x 1000)

Cooling Tower Fans

  • Cooling Tower Fan #1

  • Cooling Tower Fan #1 Drives

  • Cooling Tower Fan #1 VFD HZ

  • Cooling Tower Fan #2

  • Cooling Tower Fan #2 Drives

  • Cooling Tower Fan #2 VFD HZ

  • Cooling Tower Fan #3

  • Cooling Tower Fan #3 Drives

  • Cooling Tower Fan #3 VFD HZ

Cooling Tower Total Dissolve Solids (TDS)

  • TDS Reading

  • TDS Reading in range? (1200-2100)

Domestic Water Booster Pump

  • Pump #1

  • Pump #2

  • Pump HZ

  • Discharge Pressure

Chiller Primary Pumps

  • PCHWP #1

  • PCHWP #1 Drive

  • PCHWP #1 VFD HZ

  • PCHWP #2

  • PCHWP #2 Drive

  • PCHWP #2 VFD HZ

  • PCHWP #3

  • PCHWP #3 Drive

  • PCHWP #3 VFD HZ

Cooling Tower Pump CWP #1

  • Cooling Tower Pump CWP #1

  • Cooling Tower Pump CWP #1 Drive

  • Cooling Tower Pump CWP #1 VFD HZ

  • Cooling Tower Pump CWP #1 Suction PSI

  • Cooling Tower Pump CWP #1 Discharge PSI

Cooling Tower Pump CWP #2

  • Cooling Tower Pump CWP #2

  • Cooling Tower Pump CWP #2 Drive

  • Cooling Tower Pump CWP #2 VFD HZ

  • Cooling Tower Pump CWP #2 Suction PSI

  • Cooling Tower Pump CWP #2 Discharge PSI

Cooling Tower Pump CWP #3

  • Cooling Tower Pump CWP #3

  • Cooling Tower Pump CWP #3 Drive

  • Cooling Tower Pump CWP #3 VFD HZ

  • Cooling Tower Pump CWP #3 Suction PSI

  • Cooling Tower Pump CWP #3 Discharge PSI

Chiller Secondary Pump SCHWP #2

  • Chiller Secondary Pump SCHWP #2

  • Chiller Secondary Pump SCHWP #2 Drive

  • Chiller Secondary Pump SCHWP #2 VFD HZ

  • Chiller Secondary Pump SCHWP #2 Suction PSI

  • Chiller Secondary Pump SCHWP #2 Discharge PSI

Chiller Secondary Pump SCHWP #1

  • Chiller Secondary Pump SCHWP #1

  • Chiller Secondary Pump SCHWP #1 Drive

  • Chiller Secondary Pump SCHWP #1 VFD HZ

  • Chiller Secondary Pump SCHWP #1 Suction PSI

  • Chiller Secondary Pump SCHWP #1 Discharge PSI

South Tower 7th Floor Penthouse

    Vacuum Pump Room Temperature

Medical Vacuum Pumps

  • Medical Vacuum Pump #1

  • Medical Vacuum Pump #2

  • Medical Vacuum Tank Pressure

  • Medical Vacuum Tank Pressure in range? (18-23 HG)

Medical Air Compressor

  • Medical Air Compressor Pump #1

  • Medical Air Compressor Pump #2

  • Medical Air Compressor Pump #3

  • System PSI

  • Dewpoint Reading

  • CO2 Alarm

Medical Air Dryer

  • Dryer #1

  • Dryer #1 Filter Status

  • Dryer #2

  • Dryer #2 Filter Status

  • Dryer Output Line Pressure

  • Dryer Output Line Pressure in range? (55-65 psi)

AHU 28

  • SAF VFD Drive Left

  • SAF VFD Drive Left VFD Percent (Top Left Corner)

  • SAF VFD Drive Right

  • SAF VFD Drive Right VFD Percent (Top Left Corner)

  • RAF VFD Drive Left

  • RAF VFD Drive Left VFD Percent (Top Left Corner)

  • RAF VFD Drive Right

  • RAF VFD Drive Right VFD Percent (Top Left Corner)

AHU 27

  • RAF VFD Drive Left

  • RAF VFD Drive Left VFD Percent (Top Left Corner)

  • RAF VFD Drive Right

  • RAF VFD Drive Right VFD Percent (Top Left Corner)

  • SAF VFD Drive Left

  • SAF VFD Drive Left VFD Percent (Top Left Corner)

  • SAF VFD Drive Right

  • SAF VFD Drive Right VFD Percent (Top Left Corner)

AHU 26

  • SAF VFD Drive Left

  • SAF VFD Drive Left VFD Percent (Top Left Corner)

  • SAF VFD Drive Right

  • SAF VFD Drive Right VFD Percent (Top Left Corner)

  • RAF VFD Drive Left

  • RAF VFD Drive Left VFD Percent (Top Left Corner)

  • RAF VFD Drive Right

  • RAF VFD Drive Right VFD Percent (Top Left Corner)

South Tower 4th Floor Boiler Room/AHU 25

Boiler #7

  • Boiler #7 On/Off

  • Boiler #7 Water Temp Boiler #7 Stack Temp

Boiler #5

  • Boiler #5 On/Off

  • Boiler #5 Water Temp Boiler #5 Stack Temp

Boiler #4

  • Boiler #4 On/Off

  • Boiler #4 Water Temp Boiler #4 Stack Temp

Boiler #6

  • Boiler #6 On/Off

  • Boiler #6 Water Temp Boiler #6 Stack Temp

Boiler Water Pump #4

  • Boiler Water Pump #4 On/Off

  • Suction PSI

  • Suction PSI in range? (10-20 psi)

  • Discharge PSI

  • Discharge PSI in range? (45-65 psi)

Boiler Water Pump #5

  • Boiler Water Pump #5 On/Off

  • Suction PSI

  • Suction PSI in range? (10-20 psi)

  • Discharge PSI

  • Discharge PSI in range? (45-65 psi)

Boiler Water Pump #6

  • Boiler Water Pump #6 On/Off

  • Suction PSI

  • Suction PSI in range? (10-20 psi)

  • Discharge PSI

  • Discharge PSI in range? (45-65 psi)

Boiler Water Pump #7

  • Boiler Water Pump #7 On/Off

  • Drive Status

  • Suction PSI

  • Suction PSI in range? (10-20 psi)

  • Discharge PSI

  • Discharge PSI in range? (45-65 psi)

Domestic Hot Water

    Domestic HWH #1 Temperature Domestic HWH #2 Temperature Domestic HWH #3 Temperature Domestic Mixing Temperature

Condensate Pump

  • Condensate Pump #1 Auto/Off

  • Condensate Pump #2 Auto/Off

  • Test Pump (Mondays)

AHU 25

  • AHU 25 SAF

  • AHU 25 SAF Drives

  • AHU 25 SAF HZ

  • AHU 25 RAF

  • AHU 25 RAF Drives

  • AHU 25 RAF HZ

Second Floor Crossover (AHU 19-20)

AHU 19 (serving NSICU)

  • AHU 19 SAF

  • AHU 19 SAF Drive

  • AHU 19 SAF HZ

  • AHU 19 RAF

  • AHU 19 RAF Drive

  • AHU 19 RAF HZ

AHU 20 (serving Administration & Pharmacy)

  • AHU 20 SAF

  • AHU 20 RAF

Heat Exchanger #7 (serving NSICU, Administration & Pharmacy)

  • HWP1

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-65 psi)

  • HWP2

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-65 psi)

Condensate Pumps

  • Pump #1

  • Pump #2

  • Test Pumps (Mondays)

L&D 2nd Floor (AHU 23)

AHU 23 (Serving L & D, PPOB, MEDICAL RECORDS, & GME)

  • AHU 23 SAF

  • AHU 23 SAF Drive

  • AHU 23 SAF HZ

  • AHU 23 RAF

  • AHU 23 RAF Drive

  • AHU 23 RAF HZ

OR Mechanical Penthouse (AHU 10-21)

AHU 21 (serving OR)

  • AHU 21 SAF

  • AHU 21 SAF Drive

  • AHU 21 SAF HZ

  • AHU 21 RAF

  • AHU 21 RAF Drive

  • AHU 21 RAF HZ

AHU 10 (serving OR & Recovery)

  • AHU 10 SAF

  • AHU 10 SAF Drive

  • AHU 10 SAF HZ

  • AHU 10 RAF

  • AHU 10 SAF Drive

  • AHU 10 SAF HZ

Heat Exchanger #3 (serving OR & PACU)

  • HWP1

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • HWP2

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

Condensate Pumps

  • Pump #1

  • Pump #2

  • Test Pumps (Mondays)

Steam Pressure

  • Main Line Steam Pressure

  • Main Line Steam Pressure in range? (60-80 psi)

  • Humidifier Steam Pressure

  • Humidifier Steam Pressure in range? (20-50psi)

ED Mechanical Penthouse (AHU 3)

AHU 3 (serving Emergency Department)

  • AHU 3 SAF

  • AHU 3 SAF Drive

  • AHU 3 SAF HZ

  • AHU 3 RAF

  • AHU 3 RAF Drive

  • AHU 3 RAF HZ

3rd Floor STICU Mechanical Room (AHU 22)

AHU 22 (serving STICU)

  • AHU 22 SAF

  • AHU 22 SAF Drive

  • AHU 22 SAF HZ

  • AHU 22 RAF

  • AHU 22 RAF Drive

  • AHU 22 RAF HZ

CVICU Mechanical Room (AHU 15-16)

AHU 15 (serving CVICU)

  • AHU 15 SAF

  • AHU 15 RAF

AHU 16 (serving OR Heart Rms, OR2, & Womens Locker Rm)

  • AHU 16 SAF

  • AHU 16 SAF Drive

  • AHU 16 SAF HZ

  • AHU 16 RAF

  • AHU 16 RAF Drive

  • AHU 16 RAF HZ

Heat Exchanger #5 (serving CVICU & OR Heart Rms)

  • HWP1

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • HWP2

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

Condensate Pumps

  • Pump #1

  • Pump #2

  • Test Pumps (Mondays)

Control Air Compressor

  • Control Air Compressor #1

  • Control Air Compressor #2

  • Control Air Compressor Tank Pressure

  • Control Air Compressor Tank Pressure in range? (80-110 psi)

  • Control Air Compressor Oil Level Pump#1 (Mondays)

  • Control Air Compressor Oil Level Pump#2 (Mondays)

4th Floor Main Hospital Penthouse (AHU 4,5,6,7)

AHU 6 (serving SAME DAY SURGERY & CENTRAL STERILE)

  • AHU 6 SAF

  • AHU 6 SAF Drive

  • AHU 6 SAF %

  • AHU 6 RAF

AHU 7 (serving L&D & PPOB)

  • AHU 7 SAF

  • AHU 7 SAF Drive

  • AHU 7 SAF %

  • AHU 7 RAF

Heat Exchanger #2 (serving MAIN BUILDING)

  • HWP1

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • HWP2

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • Heating Water Supply Temperature

Control Air Compressor

  • Control Air Compressor #1

  • Control Air Compressor #2

  • Control Air Compressor Tank Pressure

  • Control Air Compressor Tank Pressure in range?

  • Oil Level Pump 1 (Mondays)

  • Oil Level Pump 2 (Mondays)

AHU 12 (serving MAIN PATIENT WINGS)

  • AHU 12 SAF

Elevator Room

    Elevator Equipment Rm Temperature

AHU 5 (serving MAIN PATIENT WINGS)

  • AHU 5 SAF

  • AHU 5 SAF Drive

  • AHU 5 SAF %

  • AHU 5 RAF

AHU 4 (serving X-RAY, LOBBBY, LAB)

  • AHU 4 SAF

  • AHU 4 SAF Drive

  • AHU 4 SAF %

  • AHU 4 RAF

2nd Floor North Mechanical Room (AHU 8,24,18)

AHU 8 (serving 1 East PATIENT WING)

  • AHU 8 SAF

  • AHU 8 RAF

Heat Exchanger #8 (serving 2 NORTH, 1 EAST, AND CARDIAC REHAB)

  • HWP #1

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • HWP #2

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • Heating Water Supply Temperature

Condensate Pumps

  • Pump #1

  • Pump #2

  • Test Pumps (Mondays)

Domestic Water Heaters (serving 1 EAST & 2 NORTH)

  • Domestic Water Heater #3

  • Domestic Water Heater #3 Temperature
  • Domestic Water Heater #4

  • Domestic Water Heater #4 Temperature

AHU 24 (serving CARDIAC REHAB)

  • AHU 24 SAF

  • AHU 24 RAF

AHU 18 (serving 2 EAST)

  • AHU 18 SAF

  • AHU 18 RAF

AHU 29 (serving RADIATION ONCOLOGY)

  • AHU 29 SAF #1

  • AHU 29 SAF #1 Drive

  • AHU 29 SAF #1 %

  • AHU 29 SAF #2

  • AHU 29 SAF #2 Drive

  • AHU 29 SAF #2 %

  • AHU 29 RAF #1

  • AHU 29 RAF #1 Drive

  • AHU 29 RAF #1 %

  • AHU 29 RAF #2

  • AHU 29 RAF #2 Drive

  • AHU 29 RAF #2 %

Condensate Pumps

  • Pump #1

  • Pump #2

  • Test Pumps (Mondays)

Heat Exchanger (LinAcc)

  • HWP1

  • HWP2

1st Floor PT Mechanical Room (AHU 17)

AHU 17 (serving PHYSICAL THERAPY)

  • AHU 17 SAF

  • AHU 17 RAF

MRI Mechanical Room (AHU 14)

AHU 14 (serving MRI & ED)

  • AHU 14 SAF

  • AHU 14 SAF Drive

  • AHU 14 SAF %

  • AHU 14 RAF

  • AHU 14 RAF Drive

  • AHU 14 RAF %

Heat Exchanger #4 (serving MRI & ED)

  • HWP #1

  • HWP #2

  • Suction PSI

  • Suction PSI in range? (15-35 psi)

  • Discharge PSI

  • Discharge PSI in range? (40-60 psi)

  • Heating Water Supply Temperature

Condensate Pumps

  • Pump #1

  • Pump #2

  • Test Pumps (Mondays)

1st Floor Special Procedures Radiology Mech. Room (AHU 11)

AHU 11 (serving SPECIAL PROCEDURES & HOLDING)

  • AHU 11 SAF

  • AHU 11 SAF Drive

  • AHU 11 SAF %

  • AHU 11 RAF

  • AHU 11 RAF Drive

  • AHU 11 RAF %

1st Floor CT Scan Mechanical Room (AHU 9)

AHU 9 (serving CT SCAN & ULTRASOUND)

  • AHU 9 SAF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.