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Incoming Inspection Form
Please fill out all the questions to the best of your ability.
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1
Name
*
This field is required.
First Name
Last Name
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2
Associated Special Project Work Order Number
*
This field is required.
This will be added to the Initial Inspection WO as updated by CMMS analyst
Number from AIMS database.
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3
Responsible Department
Clinical Technology Services
Imaging Technology Services
Equipment Cleaning and Distribution
Point Of Care Testing
Administrative
Clinical Technology Services
Clinical Technology Services
Imaging Technology Services
Equipment Cleaning and Distribution
Point Of Care Testing
Administrative
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4
Found In Use
*
This field is required.
YES
NO
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5
Multiple Entries
Click yes if you have more then one CTS#
YES
NO
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6
CTS Tag Number
*
This field is required.
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7
Is this a Parent/Child device to another CTS #
YES
NO
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8
Is this device the Parent or Child?
Please Select
Parent
Child
Please Select
Please Select
Parent
Child
Please choose one.
What CTS# is this the Parent or Child of?
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9
CTS Tag Number
For Multiple Entries
CTS Number
Serial Number
Cost Center
Number 2
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Number 3
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Number 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Number 5
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Number 6
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Number 7
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Number 8
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Number 9
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Number 10
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Number 2
Number 3
Number 4
Number 5
Number 6
Number 7
Number 8
Number 9
Number 10
CTS Number
Row 0, Column 0
Serial Number
Row 0, Column 1
Cost Center
Row 0, Column 2
CTS Number
Row 1, Column 0
Serial Number
Row 1, Column 1
Cost Center
Row 1, Column 2
CTS Number
Row 2, Column 0
Serial Number
Row 2, Column 1
Cost Center
Row 2, Column 2
CTS Number
Row 3, Column 0
Serial Number
Row 3, Column 1
Cost Center
Row 3, Column 2
CTS Number
Row 4, Column 0
Serial Number
Row 4, Column 1
Cost Center
Row 4, Column 2
CTS Number
Row 5, Column 0
Serial Number
Row 5, Column 1
Cost Center
Row 5, Column 2
CTS Number
Row 6, Column 0
Serial Number
Row 6, Column 1
Cost Center
Row 6, Column 2
CTS Number
Row 7, Column 0
Serial Number
Row 7, Column 1
Cost Center
Row 7, Column 2
CTS Number
Row 8, Column 0
Serial Number
Row 8, Column 1
Cost Center
Row 8, Column 2
1
of 9
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10
Manufacturer Specific Identification Number
i.e. Functional location Number / System ID... not needed
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11
Name Plate Details
This information is required!
Equipment Description
Manufacturer
Model Name - Make sure it is correctly cased.
Model Number - Sometimes called reference number.
Serial Number
Date of Manufacture
Date of Install - If different from date form completed.
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12
Cost Center
Please Select
106010 CFV-Nursing Administration
106015 CFV-Nursing Quality
106016 CFV-IV Therapy
106024 CFV-Centralized Telemetry
106025 CFV-6S Medical
106026 CFV-4S Medical/Telemetry
106027 CFV-5S Medical Oncology
106029 CFV-4 North Medical
106030 CFV-Antenatal Testing Unit
106031 CFV-4VPS Family Care Center
106034 CFV-3 North Nephrology
106035 CFV-3 North
106036 CFV-7S Surgical
106037 CFV-3S Medical/Telemetry
106038 CFV-2S Medical/Telemetry
106050 CFV-5N Pediatrics
106051 CFV-5N PICU Pediatric Special Care Unit
106060 BHC-Adult Psych Unit
106062 BHC-Adolescent Psych Unit
106090 CFV-Family-Centered Care Nursery
106120 CFV-ICU Intensive Care Unit
106125 CFV-NICU Neonatal Intensive Care
106136 CFV-3VPN Surgical
106137 CFV-4VPN Womans Pavilion
106138 CFV-8S Step Down
106139 CFV-3VP South
106141 CFV-Cardiac Cath Lab
106142 CFV-CSICU Cardiac Surgery ICU
106143 CFV-Electrophysiology Lab
106147 CFV-Gastro-Intestinal Lab
106150 CFV-RGEN Rehab Nursing-Gen
106152 CFV-1 West Adult Overflow
106155 CFV-RSCI Rehab Nursing
106157 CFV-REBI Rehab Nursing
106160 CFV-Hemodialysis
106170 CFV-Respiratory Care Services
106171 CFV-Lung Nodule Clinic
106173 CFV-Sleep Center
106176 OPC-CFV Sleep Center Walter Reed
106190 CFV-Labor & Delivery
106210 CFV-Operating Room
106213 CFV-CSOR Cardiac Surgery OR
106217 CFV-Short Stay Surgery
106220 CFV-PACU
106238 CFV-1N Observation
106248 CFV-1 VP
106250 CFV-Central Supply
106252 CFV-Sterile Processing
106274 CFV-Injection Series Clinic
106277 CFV-AM Admissions Unit
106279 CFV-Pediatric ED
106280 CFV-Emergency Dept
106282 CFV-2 North Observation
106283 CFV-LifeLink
106290 CFV-3 North B
106291 CFV-3 North A
106294 CFV-Chest Pain Center
106296 CFV-Cardiovascular Recovery
107010 CFV-Laboratory
107011 CFV-Core Lab
107013 CFV-Histology
107014 CFV-Phlebotomy
107019 CFV-Microbiology
107025 CFV-Transfusion Services
107026 CFV-Donor Center
107030 CFV-Cardiac Diagnostics
107035 CFV-Neurodiagnostic
107040 CFV-Radiology
107041 CFV-Diagnostic Service Center DSC
107042 CFV-Special Procedures
107044 CFV-Nuclear Medicine
107045 CFV-Breast Imaging
107046 CFV-Ultrasound
107048 CFV-CT Scan
107049 CFV-MRI
107051 CFV-Medical Oncology
107052 CFV-Radiation Therapy
107070 CFV-Pharmacy
107080 CFV-Anesthesia
107091 CFV-Physical Therapy
107092 CFV-Occupational Therapy
107093 CFV-Speech & Audiology
107094 CFV-Recreation Therapy
107128 CFV-Cardiac Rehab
107136 OPC-Medical Arts Wound Clinic
107140 OPC-CFV OB/Gyn
107142 CFV-Healthplex
108020 CFV-Training & Development
108041 CFV-GME Administration
108050 CFV-Food & Nutrition Service
108055 CICR Research Institute
108060 CFV-Engineering
108063 CFV-Clinical Technology Services
108226 CFV-PFS Registration
108311 CFV-Rehabilitation Administration
108382 CFV-Simulation Lab
207122 BHC-Community Behavioral Health Ctr
306282 EMS-Cumberland County EMS
405060 OPC-CFV Three Rivers Medical
408511 OPC-CFV Fayetteville Orthopedics and Sports Medicine
408520 OPC-CFV Pediatric Care
408525 OPC-CFV Harnett Surgical Assoc
408527 OPC-CFV Valley Orthopedics and Sports Medicine
408534 OPC-CFV Podiatry-Dunn
408535 OPC-CFV PC-Dunn Erwin
408545 OPC-CFV Hope Mills Family Care
408565 OPC-CFV PC-Clinton
408574 OPC-CFV Podiatry-Lumberton
408575 OPC-CFV PC-Lumberton
408576 OPC-CFV PC-Robeson Family Practice
408585 OPC-CFV PC-Fayetteville Family
408587 OPC-CFV General Surgery-Village
408595 OPC-CFV PC-John Smith
408600 OPC-Seniors Health Services
408605 OPC-CFV Medical Group
408610 OPC-CFV Stedman Medical Care
408620 OPC-CFV Westside Primary Care
408623 OPC-CFV PC-Highland Family Practice
408628 OPC-CFV Urology-Owen Park
408630 OPC-CFV Internal Medicine
408632 OPC-CFV Pulmonary Associates
408634 OPC-CFV Podiatry-Fayetteville
408635 OPC-CFV ENT Clinic
408636 OPC-CFV Vascular Surgery
408650 OPC-Hoke Family Medical Center
408655 OPC-CFV IM Continuity Clinic
408675 OPC-CFV Interventional Pain Specialist
408705 OPC-CFV Foot & Ankle-Lumberton
408707 OPC-CFV Foot & Ankle-Hoke
408740 OPC-Diabetes & Endocrine Center
408745 OPC-CFV Pediatric Endocrinology
408750 OPC-Valley Infectious Desease Care
408760 OPC-CFV Perinatology
408770 OPC-CFV Neurosurgery Practice
408775 OPC-CFV Neurology
408785 OPC-CFV Urology Clinic
408795 OPC-CFV Ferncreek Surgery
408800 OPC-CFV Cardiovascular & Thoracic Surgery
506173 HPN-Sleep Center
506287 HPN-Express Care
507011 HPN-Core Lab
507040 HPN-Radiology
507046 HPN-Ultrasound
507048 HPN-CT Scan
507051 HPN-Medical Oncology
507052 HPN-Radiation Therapy
507070 HPN-Pharmacy
507091 HPN-Physical Therapy
507092 HPN-Occupational Therapy
508309 HPN-Administration
509100 HPN-Family Practice Clinic
706010 HSR-Nursing Admin
706016 HSR-IV Therapy
706040 HSR-Third Floor
706041 HSR-Fourth Floor
706118 HSR-ICU/CCU
706147 HSR-GI Lab
706170 HSR-Respiratory Care
706212 HSR-Surgicare Center
706212 HSR-Surgicare Center
706250 HSR-Central Supply Service
706285 HSR-Recovery Care Center
706287 HSR-Express Care
707010 HSR-Laboratory
707030 HSR-Cardiac Diagnostics
707040 HSR-Radiology
707046 HSR-Ultrasound
707048 HSR-CT Scan
707080 HSR-Anesthesiology
707091 HSR-Physical Therapy
708050 HSR-Food & Nutrition Service
708063 HSR-Clinical Technology Services CTS
708309 HSR-Administration
806010 BCH-Nursing Administration
806022 BCH-Med/Surg
806028 OPC-Bladen Womens Health Specialists
806031 BCH-Family Care Center
806120 BCH-ICU
806170 BCH-Respiratory Therapy
806173 BCH-Sleep Lab
806200 OPC-Surgical Specialists
806210 BCH-Operating Room
806280 BCH-Emergency Department
807010 BCH-Laboratory
807040 BCH-Radiology
807070 BCH-Pharmacy
807080 BCH-Anesthesiology
807091 BCH-Physical Therapy
807128 BCH-Cardiac Rehab
808020 BCH-Training & Development
808050 BCH-Food & Nutrition Service
808063 BCH-Clinical Technology Services
808710 BCH-Employee Health
808810 OPC-BMA Elizabethtown
808811 OPC-Bladen Kids Care
808815 OPC-BMA Express Care
808820 OPC-BMA Dublin
808825 OPC-BMA Vineland Family Medicine
808830 OPC-BMA Bladenboro
808860 OPC-BMA Clarkton
808870 OPC-BMA White Lake
815115 OPC-BJH Coats Medical Services
815120 OPC-BJH Angier Medical Services
815125 OPC-BJH Lillington Med. Services
815130 OPC-BJH Dunn Medical Services
815135 OPC-BJH Harnett Internal Medicine Clinic
815140 OPC-BJH Ortho & Sport Clinic
815145 OPC-BJH Harnett OB/GYN
815165 OPC-BJH Premiere Peds-Dunn
815167 OPC-BJH Premiere Peds-Lillington
815170 OPC-BJH Buffalo Lakes Medical
815175 OPC-BJH Harnett ENT Clinic
815180 OPC-BJH Harnett Heart And Vascular Specialist
816010 BJH-Nursing Admin
816050 BJH-Pediatrics
816090 BJH-Nursery
816120 BJH-ICU
816170 BJH-Respiratory Therapy
816173 BJH-Sleep Center
816190 BJH-Labor & Delivery
816210 BJH-Operating Room
816220 BJH-PACU
816250 BJH-Central Supply
816252 BJH-Sterile Processing
816280 BJH-Emergency Department
816530 BJH-Fourth Floor Med/Surg
816535 BJH-Obstetrics (2nd Floor)
816537 BJH-Third Floor Med/Surg
817010 BJH-Laboratory
817025 BJH-Transfusion Services
817040 BJH-Radiology
817044 BJH-Nuclear Medicine
817046 BJH-Ultrasound
817048 BJH-CT Scan
817049 BJH-MRI
817070 BJH-Pharmacy
817080 BJH-Anesthesia
817082 OPC-BJH Endocrinology Clinic
817083 OPC-BJH IM Residency Clinic
817091 BJH-Physical Therapy
817092 BJH-Occupational Therapy
817093 BJH-Speech And Audiology
817128 BJH-Cardiac Rehab
817136 BJH-Wound Care
817245 BJH-Mammography
817761 BJH-Endoscopy
818020 BJH-Organization Development
818050 BJH-Food and Nutrition Svc
818060 BJH-Facility Engineering
818063 BJH-Clinical Engineering
818065 BJH-Security
818231 BJH-Information Systems
818710 BJH-Employee Health
826010 CHH-Nursing Admin
826120 CHH-ICU
826141 CHH-Cardiac Cath
826170 CHH-Respiratory Therapy
826210 CHH-Operating Room
826220 CHH-PACU
826250 CHH-Central Supply
826280 CHH-Emergency Department
826515 CHH-2 East
826525 CHH-2 West
827010 CHH-Laboratory
827040 CHH-Radiology
827044 CHH-Nuclear Medicine
827046 CHH-Ultrasound
827048 CHH-CT Scan
827049 CHH-MRI
827051 CHH-Medical Oncology
827070 CHH-Pharmacy
827080 CHH-Anesthesia
827091 CHH-Physical Therapy
827092 CHH-Occupational Therapy
827093 CHH-Speech & Audiology
827097 OPC-CHH Physical Therapy Lillington
827129 CHH-Pulmonary Rehab
827136 CHH-Wound Care
827245 CHH-Mammography
827761 CHH-Endoscopy
827771 OPC-CHH Occupational Therapy Lillington
828050 CHH-Food and Nutrition Service
828060 CHH-Facility Engineering
828063 CHH-Clinical Engineering
828065 CHH-Security
908231 CFV-Information Services & Technology
908320 CFV-Marketing & Public Relations
908326 CFV-Visitor Management
908710 CFV-Employee Health
908710 HSR-Employee Health
908720 CFV-Child Care Services
966010 Hoke-Nursing Admin
966017 Hoke-Patient Transportation
966022 Hoke-Med/Surg
966120 Hoke-ICU
966170 Hoke-Respiratory Care
966173 Hoke-Sleep Center
966190 Hoke-Labor And Delivery
966210 Hoke-Operating Room
966220 Hoke-PACU
966250 Hoke-Central Supply
966252 Hoke-Sterile Processing
966280 Hoke-Emergency Dept
966282 Hoke-EMS
966287 Hoke-Express Care
967011 Hoke-Core Lab
967013 Hoke-Histology
967019 Hoke-Microbiology
967025 Hoke-Transfusion Service
967040 Hoke-Radiology
967044 Hoke-Nuclear Medicine
967046 Hoke-Ultrasound
967048 Hoke-CT Scan
967072 Hoke-MOB Pharmacy
967080 Hoke-Anesthesiology
967091 Hoke-Physical Therapy
967092 Hoke-Occupational Therapy
967140 Hoke-OB-Gyn
967240 Hoke-MOB Radiology - HI
967245 Hoke-MOB Mammography
967246 Hoke-MOB Ultrasound - HI
967249 Hoke-MOB MRI
968020 Hoke-Education
968050 Hoke-Food & Nutrition Service
968060 Hoke-Engineering
968063 Hoke-Clinical Technology Services
968065 Hoke-Security
968231 Hoke-Information Svcs & Technology
968309 Hoke-Administration
968313 Hoke-Volunteer Services
968314 Hoke-Chaplaincy
968317 Hoke-Risk Management
968318 Hoke-Infection Prevention/Control
968320 Hoke-Marketing & Outreach
968371 Hoke-Human Resources
968710 Hoke-Employee Health
969100 Hoke-Primary Care
Please Select
Please Select
106010 CFV-Nursing Administration
106015 CFV-Nursing Quality
106016 CFV-IV Therapy
106024 CFV-Centralized Telemetry
106025 CFV-6S Medical
106026 CFV-4S Medical/Telemetry
106027 CFV-5S Medical Oncology
106029 CFV-4 North Medical
106030 CFV-Antenatal Testing Unit
106031 CFV-4VPS Family Care Center
106034 CFV-3 North Nephrology
106035 CFV-3 North
106036 CFV-7S Surgical
106037 CFV-3S Medical/Telemetry
106038 CFV-2S Medical/Telemetry
106050 CFV-5N Pediatrics
106051 CFV-5N PICU Pediatric Special Care Unit
106060 BHC-Adult Psych Unit
106062 BHC-Adolescent Psych Unit
106090 CFV-Family-Centered Care Nursery
106120 CFV-ICU Intensive Care Unit
106125 CFV-NICU Neonatal Intensive Care
106136 CFV-3VPN Surgical
106137 CFV-4VPN Womans Pavilion
106138 CFV-8S Step Down
106139 CFV-3VP South
106141 CFV-Cardiac Cath Lab
106142 CFV-CSICU Cardiac Surgery ICU
106143 CFV-Electrophysiology Lab
106147 CFV-Gastro-Intestinal Lab
106150 CFV-RGEN Rehab Nursing-Gen
106152 CFV-1 West Adult Overflow
106155 CFV-RSCI Rehab Nursing
106157 CFV-REBI Rehab Nursing
106160 CFV-Hemodialysis
106170 CFV-Respiratory Care Services
106171 CFV-Lung Nodule Clinic
106173 CFV-Sleep Center
106176 OPC-CFV Sleep Center Walter Reed
106190 CFV-Labor & Delivery
106210 CFV-Operating Room
106213 CFV-CSOR Cardiac Surgery OR
106217 CFV-Short Stay Surgery
106220 CFV-PACU
106238 CFV-1N Observation
106248 CFV-1 VP
106250 CFV-Central Supply
106252 CFV-Sterile Processing
106274 CFV-Injection Series Clinic
106277 CFV-AM Admissions Unit
106279 CFV-Pediatric ED
106280 CFV-Emergency Dept
106282 CFV-2 North Observation
106283 CFV-LifeLink
106290 CFV-3 North B
106291 CFV-3 North A
106294 CFV-Chest Pain Center
106296 CFV-Cardiovascular Recovery
107010 CFV-Laboratory
107011 CFV-Core Lab
107013 CFV-Histology
107014 CFV-Phlebotomy
107019 CFV-Microbiology
107025 CFV-Transfusion Services
107026 CFV-Donor Center
107030 CFV-Cardiac Diagnostics
107035 CFV-Neurodiagnostic
107040 CFV-Radiology
107041 CFV-Diagnostic Service Center DSC
107042 CFV-Special Procedures
107044 CFV-Nuclear Medicine
107045 CFV-Breast Imaging
107046 CFV-Ultrasound
107048 CFV-CT Scan
107049 CFV-MRI
107051 CFV-Medical Oncology
107052 CFV-Radiation Therapy
107070 CFV-Pharmacy
107080 CFV-Anesthesia
107091 CFV-Physical Therapy
107092 CFV-Occupational Therapy
107093 CFV-Speech & Audiology
107094 CFV-Recreation Therapy
107128 CFV-Cardiac Rehab
107136 OPC-Medical Arts Wound Clinic
107140 OPC-CFV OB/Gyn
107142 CFV-Healthplex
108020 CFV-Training & Development
108041 CFV-GME Administration
108050 CFV-Food & Nutrition Service
108055 CICR Research Institute
108060 CFV-Engineering
108063 CFV-Clinical Technology Services
108226 CFV-PFS Registration
108311 CFV-Rehabilitation Administration
108382 CFV-Simulation Lab
207122 BHC-Community Behavioral Health Ctr
306282 EMS-Cumberland County EMS
405060 OPC-CFV Three Rivers Medical
408511 OPC-CFV Fayetteville Orthopedics and Sports Medicine
408520 OPC-CFV Pediatric Care
408525 OPC-CFV Harnett Surgical Assoc
408527 OPC-CFV Valley Orthopedics and Sports Medicine
408534 OPC-CFV Podiatry-Dunn
408535 OPC-CFV PC-Dunn Erwin
408545 OPC-CFV Hope Mills Family Care
408565 OPC-CFV PC-Clinton
408574 OPC-CFV Podiatry-Lumberton
408575 OPC-CFV PC-Lumberton
408576 OPC-CFV PC-Robeson Family Practice
408585 OPC-CFV PC-Fayetteville Family
408587 OPC-CFV General Surgery-Village
408595 OPC-CFV PC-John Smith
408600 OPC-Seniors Health Services
408605 OPC-CFV Medical Group
408610 OPC-CFV Stedman Medical Care
408620 OPC-CFV Westside Primary Care
408623 OPC-CFV PC-Highland Family Practice
408628 OPC-CFV Urology-Owen Park
408630 OPC-CFV Internal Medicine
408632 OPC-CFV Pulmonary Associates
408634 OPC-CFV Podiatry-Fayetteville
408635 OPC-CFV ENT Clinic
408636 OPC-CFV Vascular Surgery
408650 OPC-Hoke Family Medical Center
408655 OPC-CFV IM Continuity Clinic
408675 OPC-CFV Interventional Pain Specialist
408705 OPC-CFV Foot & Ankle-Lumberton
408707 OPC-CFV Foot & Ankle-Hoke
408740 OPC-Diabetes & Endocrine Center
408745 OPC-CFV Pediatric Endocrinology
408750 OPC-Valley Infectious Desease Care
408760 OPC-CFV Perinatology
408770 OPC-CFV Neurosurgery Practice
408775 OPC-CFV Neurology
408785 OPC-CFV Urology Clinic
408795 OPC-CFV Ferncreek Surgery
408800 OPC-CFV Cardiovascular & Thoracic Surgery
506173 HPN-Sleep Center
506287 HPN-Express Care
507011 HPN-Core Lab
507040 HPN-Radiology
507046 HPN-Ultrasound
507048 HPN-CT Scan
507051 HPN-Medical Oncology
507052 HPN-Radiation Therapy
507070 HPN-Pharmacy
507091 HPN-Physical Therapy
507092 HPN-Occupational Therapy
508309 HPN-Administration
509100 HPN-Family Practice Clinic
706010 HSR-Nursing Admin
706016 HSR-IV Therapy
706040 HSR-Third Floor
706041 HSR-Fourth Floor
706118 HSR-ICU/CCU
706147 HSR-GI Lab
706170 HSR-Respiratory Care
706212 HSR-Surgicare Center
706212 HSR-Surgicare Center
706250 HSR-Central Supply Service
706285 HSR-Recovery Care Center
706287 HSR-Express Care
707010 HSR-Laboratory
707030 HSR-Cardiac Diagnostics
707040 HSR-Radiology
707046 HSR-Ultrasound
707048 HSR-CT Scan
707080 HSR-Anesthesiology
707091 HSR-Physical Therapy
708050 HSR-Food & Nutrition Service
708063 HSR-Clinical Technology Services CTS
708309 HSR-Administration
806010 BCH-Nursing Administration
806022 BCH-Med/Surg
806028 OPC-Bladen Womens Health Specialists
806031 BCH-Family Care Center
806120 BCH-ICU
806170 BCH-Respiratory Therapy
806173 BCH-Sleep Lab
806200 OPC-Surgical Specialists
806210 BCH-Operating Room
806280 BCH-Emergency Department
807010 BCH-Laboratory
807040 BCH-Radiology
807070 BCH-Pharmacy
807080 BCH-Anesthesiology
807091 BCH-Physical Therapy
807128 BCH-Cardiac Rehab
808020 BCH-Training & Development
808050 BCH-Food & Nutrition Service
808063 BCH-Clinical Technology Services
808710 BCH-Employee Health
808810 OPC-BMA Elizabethtown
808811 OPC-Bladen Kids Care
808815 OPC-BMA Express Care
808820 OPC-BMA Dublin
808825 OPC-BMA Vineland Family Medicine
808830 OPC-BMA Bladenboro
808860 OPC-BMA Clarkton
808870 OPC-BMA White Lake
815115 OPC-BJH Coats Medical Services
815120 OPC-BJH Angier Medical Services
815125 OPC-BJH Lillington Med. Services
815130 OPC-BJH Dunn Medical Services
815135 OPC-BJH Harnett Internal Medicine Clinic
815140 OPC-BJH Ortho & Sport Clinic
815145 OPC-BJH Harnett OB/GYN
815165 OPC-BJH Premiere Peds-Dunn
815167 OPC-BJH Premiere Peds-Lillington
815170 OPC-BJH Buffalo Lakes Medical
815175 OPC-BJH Harnett ENT Clinic
815180 OPC-BJH Harnett Heart And Vascular Specialist
816010 BJH-Nursing Admin
816050 BJH-Pediatrics
816090 BJH-Nursery
816120 BJH-ICU
816170 BJH-Respiratory Therapy
816173 BJH-Sleep Center
816190 BJH-Labor & Delivery
816210 BJH-Operating Room
816220 BJH-PACU
816250 BJH-Central Supply
816252 BJH-Sterile Processing
816280 BJH-Emergency Department
816530 BJH-Fourth Floor Med/Surg
816535 BJH-Obstetrics (2nd Floor)
816537 BJH-Third Floor Med/Surg
817010 BJH-Laboratory
817025 BJH-Transfusion Services
817040 BJH-Radiology
817044 BJH-Nuclear Medicine
817046 BJH-Ultrasound
817048 BJH-CT Scan
817049 BJH-MRI
817070 BJH-Pharmacy
817080 BJH-Anesthesia
817082 OPC-BJH Endocrinology Clinic
817083 OPC-BJH IM Residency Clinic
817091 BJH-Physical Therapy
817092 BJH-Occupational Therapy
817093 BJH-Speech And Audiology
817128 BJH-Cardiac Rehab
817136 BJH-Wound Care
817245 BJH-Mammography
817761 BJH-Endoscopy
818020 BJH-Organization Development
818050 BJH-Food and Nutrition Svc
818060 BJH-Facility Engineering
818063 BJH-Clinical Engineering
818065 BJH-Security
818231 BJH-Information Systems
818710 BJH-Employee Health
826010 CHH-Nursing Admin
826120 CHH-ICU
826141 CHH-Cardiac Cath
826170 CHH-Respiratory Therapy
826210 CHH-Operating Room
826220 CHH-PACU
826250 CHH-Central Supply
826280 CHH-Emergency Department
826515 CHH-2 East
826525 CHH-2 West
827010 CHH-Laboratory
827040 CHH-Radiology
827044 CHH-Nuclear Medicine
827046 CHH-Ultrasound
827048 CHH-CT Scan
827049 CHH-MRI
827051 CHH-Medical Oncology
827070 CHH-Pharmacy
827080 CHH-Anesthesia
827091 CHH-Physical Therapy
827092 CHH-Occupational Therapy
827093 CHH-Speech & Audiology
827097 OPC-CHH Physical Therapy Lillington
827129 CHH-Pulmonary Rehab
827136 CHH-Wound Care
827245 CHH-Mammography
827761 CHH-Endoscopy
827771 OPC-CHH Occupational Therapy Lillington
828050 CHH-Food and Nutrition Service
828060 CHH-Facility Engineering
828063 CHH-Clinical Engineering
828065 CHH-Security
908231 CFV-Information Services & Technology
908320 CFV-Marketing & Public Relations
908326 CFV-Visitor Management
908710 CFV-Employee Health
908710 HSR-Employee Health
908720 CFV-Child Care Services
966010 Hoke-Nursing Admin
966017 Hoke-Patient Transportation
966022 Hoke-Med/Surg
966120 Hoke-ICU
966170 Hoke-Respiratory Care
966173 Hoke-Sleep Center
966190 Hoke-Labor And Delivery
966210 Hoke-Operating Room
966220 Hoke-PACU
966250 Hoke-Central Supply
966252 Hoke-Sterile Processing
966280 Hoke-Emergency Dept
966282 Hoke-EMS
966287 Hoke-Express Care
967011 Hoke-Core Lab
967013 Hoke-Histology
967019 Hoke-Microbiology
967025 Hoke-Transfusion Service
967040 Hoke-Radiology
967044 Hoke-Nuclear Medicine
967046 Hoke-Ultrasound
967048 Hoke-CT Scan
967072 Hoke-MOB Pharmacy
967080 Hoke-Anesthesiology
967091 Hoke-Physical Therapy
967092 Hoke-Occupational Therapy
967140 Hoke-OB-Gyn
967240 Hoke-MOB Radiology - HI
967245 Hoke-MOB Mammography
967246 Hoke-MOB Ultrasound - HI
967249 Hoke-MOB MRI
968020 Hoke-Education
968050 Hoke-Food & Nutrition Service
968060 Hoke-Engineering
968063 Hoke-Clinical Technology Services
968065 Hoke-Security
968231 Hoke-Information Svcs & Technology
968309 Hoke-Administration
968313 Hoke-Volunteer Services
968314 Hoke-Chaplaincy
968317 Hoke-Risk Management
968318 Hoke-Infection Prevention/Control
968320 Hoke-Marketing & Outreach
968371 Hoke-Human Resources
968710 Hoke-Employee Health
969100 Hoke-Primary Care
Cost Center
Please Select
Tele Box
Defibrillator
Transport Monitor
Mobile Radiological Device
Other.
Please Select
Please Select
Tele Box
Defibrillator
Transport Monitor
Mobile Radiological Device
Other.
Wireless Device?
Please Select
Ground
1st
2nd
3rd
4th
5th
6th
7th
8th
Please Select
Please Select
Ground
1st
2nd
3rd
4th
5th
6th
7th
8th
Floor
Room/Holding Location
Area - Does not have to be the Cost Center
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13
Does This device require a PM?
*
This field is required.
YES
NO
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14
PM Month Required
N/A
January
February
March
April
May
June
July
August
September
October
November
December
N/A
N/A
January
February
March
April
May
June
July
August
September
October
November
December
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15
PM Frequency
Please verify this with your supervisor - AEM in use!
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16
Purchasing Information
Get this information from Supply Chain.
Supplier - not required - but if known please complete.
PO Number
Purchase Cost
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Capital Lease
CFVHS Owned
CFVHS Refurbished
Non-Owned CFVHS
Operating Lease
Vendor Owned
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Please Select
Capital Lease
CFVHS Owned
CFVHS Refurbished
Non-Owned CFVHS
Operating Lease
Vendor Owned
Ownership
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17
Warranty Information
*
This field is required.
Please verify with manufacturer.
Term/Period - This can be N/A if found in use.
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Parts
Labor
Warranty
Warranty
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Parts
Labor
Warranty
Warranty Type
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18
Electrical Safety Questionnaire
Reference Manual: NFPA 99, Chapter 9
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19
Electrical Safety Results
Please Select
Pass: Class I <= 500 µA Outside Patient Care Area
Fail
N/A
Please Select
Please Select
Pass: Class I <= 500 µA Outside Patient Care Area
Fail
N/A
Current Leakage
Please Select
Pass: <= 0.5 Ohms
Fail
N/A
Please Select
Please Select
Pass: <= 0.5 Ohms
Fail
N/A
Ground Continuity
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20
Has this device been evaluated by a qualified testing laboratory.
*
This field is required.
YES
NO
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21
HIPPA Questionnaire
*
This field is required.
Does the device have a graphical user interface?
YES
NO
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22
User Interface
Base Operating System
Application Software Revision
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23
HIPPA Questionnaire 2
*
This field is required.
Does the device connect to the network?
YES
NO
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24
Network Information
Wired
Wireless
Wired
Wireless
Connection Type
MAC Address
Please Select
Static IP
Dynamic IP - i.e. DHCP
Please Select
Please Select
Static IP
Dynamic IP - i.e. DHCP
How does Device get its IP address?
IP Address
Wireless IP Address
Wireless Frequency
Channel Number
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25
Email
*
This field is required.
Please supply an E-mail address and keep a copy for your records.
example@example.com
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26
Please sign:
*
This field is required.
This is a Legal Document and this signature is required for completion
Clear
The completed form will be e-mailed to the database administrator.
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27
Tags
Todo
In Progress
Done
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Should be Empty:
Incoming Inspection Form
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