Information

  • Campus

  • Department/Area

  • Conducted on

  • Prepared by

Machine Details

Ice Machine Information

  • Machine Location

  • Serial Number

  • Due Date Sticker

  • If Yes, Date on Sticker:

  • Black or Pink/Orange Mold present?

  • If yes, location of mold:

  • Is tray under ice spout clean?

  • If no, explain:

  • Does the water spout appear clean?

  • If no, explain:

  • Is calcification, color coating present on spout?

  • If yes, explain:

Machine Utilization

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Condition

  • Container Type

  • Specify "Other" Type:

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

Usage Observation

  • Person Using Machine

  • Specify "Other" Role:

  • Container Type

  • Specify "Other" Type:

  • Container Condition

  • Dumping Contents into Ice Machine Drain

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