Add location
Select date


Call number

Member Company

Technician Signature

Technician Name

End User Name

Select date
End User Signature
Activity Summary
Trip 1
Trip 2
Trip 3
Equipment Information

Model Number

Serial Number


Photos of Issues
Actions Taken


Expense 1

Expense 2

Expense 3

Expense 4

Shipping Tracking Numbers

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.