TIBBİ CİHAZ ARIZA TALEP VE TAKİP FORMU

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MC.FR.003 - TIBBİ CİHAZ ARIZA TALEP VE TAKİP FORMU

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Demo Hastanesi (Prokalite.Com) TIBBİ CİHAZ ARIZA TALEP VE TAKİP FORMU

Doküman Kodu: MC.FR.003

Yayın Tarihi: 10.07.2015

Revizyon Tarihi: 14.10.2022

Revizyon No: 3

Sayfa: Otomatik

ARIZA BİLDİRİLEN SERVİS / BİRİM	ARIZA TALEBİNİ BİLDİREN KİŞİ	BİLDİRİMİ YAPAN TEL. NO.	BİLDİRİM YAPILAN CİHAZIN ADI	ARIZALI CİHAZA AİT KÜNYE NUMARASI	ARIZA TARİHİ	ARIZA SAATİ	ARIZA BİLDİRENİN İMZASI

TALEP EDİLEN ARIZAYA AİT AÇIKLAMA:
GÖREVLENDİRMEYİ YAPAN	GÖREVLENDİRİLEN PERSONEL		GÖREVLENDİRİLME TARİHİ		GÖREVLENDİRME SAATİ		GÖREVLENDİRİLENİN İMZASI

ARIZA ÇÖZÜM TÜRÜ BELİRLEME ▢ HİZMET ALIMI BİYOMEDİKAL DAYANIKLI TAŞINIR ▢ BAKIM-ONARIM ANLAŞMASI KAP. BİYOMEDİKAL DAY. TAŞINIR				▢ GARANTİ KAPSAMINDA BİYOMEDİKAL DAYANIKLI TAŞINIR ▢ B.&O. KAPSAMINDA KMHB TAR. SAĞLANAN BİYOMED. DAY. TAŞINIR
MÜDAHALE SONUCU						TARİH	SAAT

MÜDAHALEYİ YAPAN / İMZA				CİHAZI KULLANICISI / İMZA
KURUM DIŞI KAYNAK KULLANIM SEBEBİ						TARİH	SAAT
BİYOMEDİKAL TÜKETİM MALZEMESİ TEDARİK
SIRA NO	MALZ.TAŞ. KODU	MALZEME ADI			MİKTARI	AÇIKLAMA
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BİYOMEDİKAL TEKNİK HİZMET TEDARİK TEDARİK EDİLECEK BİY. TEKNİK HİZMET TÜRÜ
MÜDAHALEYİ YAPAN / İMZA		CİHAZ KULLANICISI / İMZA			KLİNİK MÜHENDİSLİK HİZMETLERİ SORUMLUSU / İMZA
ARIZA SONUÇ AÇIKLAMA :					ARIZA BİTİŞ TARİHİ:
ONAY ▢ GÖREVLİ TEKNİK PERSONEL / İMZA				ONAY ▢ CİHAZ KULLANICISI / İMZA

<table style="border-collapse:collapse; height:1100px; width:882px" class=" cke_show_border" cellspacing="0"><tbody><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:85px; text-align:center; vertical-align:middle; width:110px">ARIZA BİLDİRİLEN SERVİS / BİRİM</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">ARIZA TALEBİNİ BİLDİREN KİŞİ</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">BİLDİRİMİ YAPAN TEL. NO.</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">BİLDİRİM YAPILAN CİHAZIN ADI</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">ARIZALI CİHAZA AİT KÜNYE NUMARASI</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">ARIZA TARİHİ</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">ARIZA SAATİ</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:110px">ARIZA BİLDİRENİN İMZASI</td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:39px; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"> </td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:64px; text-align:left; vertical-align:top">TALEP EDİLEN ARIZAYA AİT AÇIKLAMA:</td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:51px; text-align:center; vertical-align:middle; width:110px">GÖREVLENDİRMEYİ YAPAN</td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:220px">GÖREVLENDİRİLEN PERSONEL</td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:220px">GÖREVLENDİRİLME TARİHİ</td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle; width:220px">GÖREVLENDİRME SAATİ</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:center; vertical-align:middle; width:110px">GÖREVLENDİRİLENİN İMZASI</td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:44px; vertical-align:bottom"> </td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle"> </td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle"> </td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td></tr><tr><td colspan="4" style="border-bottom:1px solid black; border-left:1px solid black; border-right:.7px solid black; border-top:1px solid black; height:51px; text-align:left; vertical-align:top; width:440px">ARIZA ÇÖZÜM TÜRÜ BELİRLEME ▢ HİZMET ALIMI BİYOMEDİKAL DAYANIKLI TAŞINIR ▢ BAKIM-ONARIM ANLAŞMASI KAP.  BİYOMEDİKAL DAY. TAŞINIR</td><td colspan="4" style="border-bottom:1px solid black; border-left:none; border-right:.7px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:440px"> ▢ GARANTİ KAPSAMINDA BİYOMEDİKAL DAYANIKLI TAŞINIR ▢  B.&O. KAPSAMINDA KMHB TAR. SAĞLANAN BİYOMED. DAY. TAŞINIR</td></tr><tr><td colspan="6" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:17px; text-align:left; vertical-align:top">MÜDAHALE SONUCU</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">TARİH</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">SAAT</td></tr><tr><td colspan="6" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:50px; text-align:left; vertical-align:top"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td></tr><tr><td colspan="4" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:50px; text-align:center; vertical-align:top">MÜDAHALEYİ YAPAN / İMZA</td><td colspan="4" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top">CİHAZI KULLANICISI / İMZA</td></tr><tr><td colspan="6" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:63px; text-align:center; vertical-align:top">KURUM DIŞI KAYNAK KULLANIM SEBEBİ</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:top">TARİH</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:top">SAAT</td></tr><tr><td colspan="8" style="border-bottom:none; border-left:none; border-right:none; border-top:1px solid black; height:17px; text-align:center; vertical-align:bottom">BİYOMEDİKAL TÜKETİM MALZEMESİ TEDARİK</td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:17px; text-align:center; vertical-align:middle">SIRA NO</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle">MALZ.TAŞ. KODU</td><td colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle">MALZEME ADI</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle">MİKTARI</td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle">AÇIKLAMA</td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:21px; text-align:center; vertical-align:bottom">1</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">   </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">  </td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:21px; text-align:center; vertical-align:bottom">2</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">   </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">  </td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:21px; text-align:center; vertical-align:bottom">3</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">   </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">  </td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:21px; text-align:center; vertical-align:bottom">4</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">   </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">  </td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:21px; text-align:center; vertical-align:bottom">5</td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">   </td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"> </td><td rowspan="1" colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom">  </td></tr><tr><td colspan="3" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:45px; text-align:left; vertical-align:top; width:330px">BİYOMEDİKAL TEKNİK HİZMET TEDARİK TEDARİK EDİLECEK BİY. TEKNİK HİZMET TÜRÜ</td><td colspan="5" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top"> </td></tr><tr><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:55px; text-align:center; vertical-align:top">MÜDAHALEYİ YAPAN / İMZA</td><td colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top">CİHAZ KULLANICISI / İMZA</td><td colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top">KLİNİK MÜHENDİSLİK HİZMETLERİ SORUMLUSU / İMZA</td></tr><tr><td colspan="5" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:47px; text-align:center; vertical-align:top">ARIZA SONUÇ AÇIKLAMA :</td><td colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top">ARIZA BİTİŞ TARİHİ:</td></tr><tr><td colspan="4" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:56px; text-align:center; vertical-align:top">ONAY ▢ GÖREVLİ TEKNİK PERSONEL / İMZA</td><td colspan="4" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top">ONAY ▢ CİHAZ KULLANICISI / İMZA</td></tr></tbody></table>

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Malzeme ve Cihaz Yönetimi - Form

MC.FR.003 - TIBBİ CİHAZ ARIZA TALEP VE TAKİP FORMU

PDF Dokümanı Gör

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