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                                                                                                                                                                                                                                                                                                                                                                               YOUR HOSPITAL NAME                                                                                                                                        Request for Maintenance, Repairs, Housekeeping, or Set Up                                                                                                                                                                                                                                                                                ╔════════════╤═════════╤════════════╤══════════════╤════════════╤═════════════╗                                                                                           ║Date Issued:│Time:    │Date Wanted:│ Requested By:│Approved By:│Department:  ║                                                                                           ║            │■ am ■ pm│            │              │            │             ║                                                                                           ╟────────────┴─────────┴────────────┴──────────────┼────────────┴─────────────╢                                                                                           ║Equipment I.D. or Tag Number:                     │   Telephone:             ║                                                                                           ╟──────────────────────────────────────────────────┴──────────────────────────╢                                                                                           ║Location of Work (be specific):                                              ║                                                                                           ╠════════════════════════════════════════════════╦════════════════════════════╣                                                                                           ║Detail Description of Work Required:            ║    Maintenance Use Only:   ║                                                                                           ║                                                ╟────────────────────────────╢                                                                                           ╟────────────────────────────────────────────────╢Parts on Order, PO#         ║                                                                                           ╟────────────────────────────────────────────────╢Est. Arrival Date:          ║                                                                                           ╟────────────────────────────────────────────────╫────────────────────────────╢                                                                                           ╟────────────────────────────────────────────────╢Parts on Back Order, PO#    ║                                                                                           ╟────────────────────────────────────────────────╢Est. Arrival Date:          ║                                                                                           ╟────────────────────────────────────────────────╫────────────────────────────╢                                                                                           ╟────────────────────────────────────────────────╢Parts not Available -       ║                                                                                           ╟────────────────────────────────────────────────╢Date:                       ║                                                                                           ╟────────────────────────────────────────────────╬════════════════════════════╣                                                                                           ╟────────────────────────────────────────────────╢Parts & Materials Used:     ║                                                                                           ╟────────────────────────────────────────────────╫────────────────────────────╢                                                                                           ╟────────────────────────────────────────────────╫────────────────────────────╢                                                                                           ╠═══════════════╤═════════════════╤══════════════╬────────────────────────────╢                                                                                           ║Date Completed:│ By:             │Hours Worked: ╟────────────────────────────╢                                                                                           ║               │                 │              ╟────────────────────────────╢                                                                                           ╠═══════════════╧══════╤══════════╧══════════════╬────────────────────────────╢                                                                                           ║ Returned to Service  │  Removed from Service   ╟────────────────────────────╢                                                                                           ╠══════════════════════╧═════════════════════════╩════════════════════════════╣                                                                                           ║Maintenance Dept. Comments:                                                  ║                                                                                           ╚═════════════════════════════════════════════════════════════════════════════╝