Title Page
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Audit Title
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Department
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Conducted on
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Device Location
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Prepared by
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Audit by
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Table Head Extensions
Head Supports / Extensions
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Device Name
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Asset / Reference Number
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Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
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Function / Safety
- Yes
- No
- N/A
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Bed Extentions
Urology / Neuro spine and Leg extensions /
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Device Name
-
Asset / Reference Number
-
Function / Safety
- Yes
- No
- N/A
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Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Pronation Devices
Prone Gell Pads / Wilson Frame
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Device Name
-
Asset / Reference Number
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Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Leg Holders
Lithotomy Poles / Hydraulic leg Holders
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Device Name
-
Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Flat Gell Pads
Short and Long Flat Gell Pads
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Device Name
-
Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Head Support Pronation Gell Pad
Pronation Face Gell pads
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Device Name
-
Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Lateral Support Gell Pads
lateral foldable gel Pads
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Device Name
-
Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Lateral Supports
Side supports with pads
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Device Name
-
Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Ortho Black Pads
black Pads
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Device Name
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Asset / Reference Number
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Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Ortho Black Pads
black Pads
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Device Name
-
Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Lateral Arm Supports
Lateral Arm Holders
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Device Name
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Asset / Reference Number
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Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
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Function / Safety
- Yes
- No
- N/A
Hand Tables
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Device Name
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Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
-
Table ArmBoards
OR Table Armboards
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Device Name
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Asset / Reference Number
-
Mattress Integrity
- Intact
- With Discolorations
- With some tear
- With splitting or loose parts
- Does not Recoils to normal size when compressed
- Size is not proportion to bed frame
-
Function / Safety
- Yes
- No
- N/A
