PREVENTIVE MAINTENANCE REPORT

Equipment Name: Model: Inventory#: For the Month Of:

Inspected Item Inspected Comments
Yes No
A. External visual check. This checklist should be
applied to determine the condition of all items
1. The overall appearance and finish of the item
will be up to organizational standards
2. Interior and exterior of the item will be free of
rust, corrosion, solutions, dirt, lint, and
deposits
3. Doors, drawers, panels, shelves, catches,
latches, hinges, stops, door pulls, handles,
knobs, and casters will be properly tightened
or adjusted to operate smoothly
4. Component holders, clips, and receptacles
will be intact and properly adjusted
5. Control knobs, mechanical locks, and levers
will be securely attached to the driven element
and properly indexed
6. Nuts, bolts, screws, and other hardware will be
tight and in good condition
B. Electrical/electronic. This checklist will be
applied to determine the condition of items
which employ electrical or electronic
components
1. Electrical connectors (jacks, receptacles, or
plugs)will be of approved type, free of cracks
or breaks, and properly attached to the line
cord or cable. Mechanical indexing
mechanisms to prevent improper alignment or
mating of plugs and receptacles will be free
from wear or damage.
2. Cables, cords, and internal wiring will be of an
approved type and of proper wire size to safely
carry the required current. In addition, all
cables, cords, and internal wiring will be of
sufficient length and free of unsafe or unsightly
splices and of frayed, cracked, abraded, or
brittle insulation.
3. Cables, clips, studs, and terminals will be free
of dirt, rust, corrosion, and other deposits
4. Switches, circuit breakers, relay points, and
selectors will not be dirty, corroded,
excessively worn, or pitted
5. Grounding systems will be of an approved type
and properly installed
6. All electrical components (relays, transformers,
 capacitors, electron tubes and resistors) will
operate without overheating
7. Heating elements will produce and maintain
the temperature rise required for proper
operation
8. Batteries will be properly charged and free of
cracks, breaks, or leaks. Electrolyte of wet cell
batteries will be at the proper level
9. Electrical leakage currents shall be within
acceptable limits
C. Positive/negative pressure. This checklist will
be applied to determine the condition of items
which involve positive or negative pressures
1. High pressure tubing will conform to the
above and be free of leaks and frayed
covering. All fittings and connectors will be in
good condition and securely attached to hose
ends.
2. All controls, regulators, flow meters, and flush
valves will be properly adjusted to accurately
regulate flow of gas. All temperature indicators
will be checked to ensure accuracy.
D. Heating/cooling/mixing. This checklist will be
applied to determine the condition of items
which heat, cool, regulate, mix, pump, or
circulate water and/or produce steam
1. All water and steam chambers will be free of
excessive rust, corrosion, and lime deposits
2. All gasket material (such as rubber, cork, and
composition type) will be free of breaks or
wear which might result in an improper seal.
3. Door and lid closing mechanisms will operate
freely and be adjusted to ensure a proper seal
4. There will be no leaks (steam or water) in the
plumbing, valves, valve packing, regulators,
boiling chamber, tanks, or pumps.
5. All valves, regulators, controls, steam traps,
and vacuum breakers will operate properly.
6. The heating system (electrical, fuel, or steam)
will provide the proper temperature and/or
pressure in the prescribed time under normal
operation
7. Low water cutoff and boiling point cutoff
switches will function properly
Maintenance Technician:
Name: Adem Ebrahim, BME Signature: _____________ Date: ______________.
Equipment user:
Name: ___________________ Signature: _____________ Date:_______________.
 Corrective Maintenance Report Form

Equipment name:
Model No:
Inventory No:
Machine location:

Description of maintenance issue:

Action Taken:

Reported by: Adem Ebrahim, BME Signature: __________ Date: ______________.

For Equipment user:

Comment

Works Completed

Approved by: ___________________ Signature: _____________ Date:__________