Asset / Reference number

Action Plan / Issue Management
Date and time of issue report

Report received by :

Employee Id


Contact number

Reported to Manager / Supervisor / Charge Nurse

Reported to Biomed

For replacement

For repair

To order new Parts

For evaluation

Temporary replacement / Back up

With biomed

To condemn

Resolved issue

Was the issue resolved?

Repaired / Refurbished

Replaced / New

Partial repair

Temporary Back up Replacement

Attach photo as needed
Sign to complete once issue resolved


Employee ID

Sign here
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.