Information
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Conducted on
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Document No.
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Prepared by
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UTMB Healthcare Move Checklist
Project Name:
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Project Name:
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Project Number: 2010-0787
Site Location: 5712 S Claiborne Ave., New Orleans, LA 70125
Contractor: Ellis Construction
Jacobs/CSRS PM: Sonji White -
Project Number: 2011-0861
Site Location: 3019 Canal St., New Orleans, LA 70119
Contractor: Tuna Construction
Jacobs/CSRS PM: Sonji White -
Date of visit.
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Time In:
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Time Out:
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Weather:
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Temperature:
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Report Submitted By:
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Quality:
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Observations/General Comments
Observation
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Floor:
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Room #:
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Room Type
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Patient Room
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Vacuum Regulators
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Vacuum Regulator Quantity
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Flow meters
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Flow Meter Quantity
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Specialty Soap & Dispensers
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Specialty Soap & Dispensers Quantity
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Sharps Container and Holder
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Sharps Container and Holder Quantity
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Gloves
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Gloves Quantity
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Glove Holder
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Glove Holder Quantity
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Hand Sanitizer
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Hand Sanitizer Quantity
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Telephone
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Telephone Quantity
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Clock
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Clock Quantity
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Linen Hamper
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Linen Hamper Quantity
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Video Signal Activation
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Television
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Television Quantity
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White Board
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White Board Quantity
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White Board Marker Holder
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White Board Marker Holder Quantity
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Markers and Erasers
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Markers and Erasers Quantity
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Patient rights Poster
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Patients RIght Poster Quantity
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Pain Poster
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Pain Poster Quantity
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Call Light system
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Pillow Speaker
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PIllow Speaker Quantity
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Check all lights
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Condition of Lights
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Blinds
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Privacy Curtains
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Monitor Brackets
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Monitor Bracket Quantity
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Saniglaze restrooms
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Make Beds
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Bathroom
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Trash cans
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Trash Can Quantity
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Shower Curtain
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Toilet Paper Holder
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Toilet Paper
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Paper Towel Dispenser
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Paper Towel Dispenser Quantity
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Paper Towels
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Soap Dispenser
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Soap Dispensor Quantity
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Soap
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Soap Quantity
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Water Filters - Sink (Vendor)
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Water Filter (Vendor) Quantity
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Water Filters - Sink (Maintenance)
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Water Filters (Maintenance) Quantity
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Check Lighting
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Condition of Lights
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Check Ceramic finishes
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Condition of Finishes
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Check Flooring finishes
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Condition of Finishes
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Beds
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Bed Quantity
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Bed Side Tables
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Bed Side Table Quantity
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Over Bed Tables
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Over Bed Table Quantity
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Trash cans
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Trash Can Quantity
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Nursing Station
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Patient White Board
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Omnicell
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Pyxis
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C-Locker
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File Cabinet under Counter
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Linen Carts
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Medical Refrigerator
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PACS
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Glucometers
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Med Frig Key
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Task Chairs
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Computer
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Monitor
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Grease Board
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NC Master
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Galley
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Refrigerator
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Microwave
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Coffee Maker
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Coffee Pots
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Sink
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Ice Machine
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Observation:
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