MC.FR.003 - 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

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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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5
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

Malzeme ve Cihaz Yönetimi bölümündeki diğer form örnekleri

Tümünü gör (15)

MC.FR.001 CİHAZ ENVANTERİ FORMU MC.FR.001 TEKERLEKLİ SANDALYE KONTROL FORMU MC.FR.002 BİYOMEDİKAL DAYANIKLI TAŞINIRLARIN ÇALIŞABİLİRLİK-AKTİF FAALİYET SÜRELERİ TAKİP FORMU MC.FR.002 HASTA KARYOLASI SEDYE VE TEKERLEKLİ SANDALYE KONTROL FORMU MC.FR.004 BİYOMEDİKAL DAYANIKLI TAŞINIR AKTİF FAALİYET SÜRELERİ ANALİZ FORMU- HİZMET ALIMI İLE MC.FR.005 SPLİT(DUVAR TİPİ) KLİMA BAKIM VE KONTROL FORMU MC.FR.006 MERKEZİ KLİMA SANTRALİ BAKIM VE KONTROL FORMU MC.FR.007 İHTİYAÇ TALEP FORMU

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<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"><span style="font-size:12px"><span style="color:black">ARIZA BİLDİRİLEN SERVİS / BİRİM</span></span></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"><span style="font-size:12px"><span style="color:black">ARIZA TALEBİNİ BİLDİREN KİŞİ</span></span></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"><span style="font-size:12px"><span style="color:black">BİLDİRİMİ YAPAN TEL. NO.</span></span></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"><span style="font-size:12px"><span style="color:black">BİLDİRİM YAPILAN CİHAZIN ADI</span></span></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"><span style="font-size:12px"><span style="color:black">ARIZALI CİHAZA AİT KÜNYE NUMARASI</span></span></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"><span style="font-size:12px"><span style="color:black">ARIZA TARİHİ</span></span></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"><span style="font-size:12px"><span style="color:black">ARIZA SAATİ</span></span></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"><span style="font-size:12px"><span style="color:black">ARIZA BİLDİRENİN İMZASI</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom; width:110px"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">TALEP EDİLEN ARIZAYA AİT AÇIKLAMA:</span></span></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"><span style="font-size:12px"><span style="color:black">GÖREVLENDİRMEYİ YAPAN</span></span></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"><span style="font-size:12px"><span style="color:black">GÖREVLENDİRİLEN PERSONEL</span></span></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"><span style="font-size:12px"><span style="color:black">GÖREVLENDİRİLME TARİHİ</span></span></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"><span style="font-size:12px"><span style="color:black">GÖREVLENDİRME SAATİ</span></span></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"><span style="font-size:12px"><span style="color:black">GÖREVLENDİRİLENİN İMZASI</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black"><span style="color:black"><strong>ARIZA ÇÖZÜM TÜRÜ BELİRLEME</strong></span></span></span><br><span style="font-size:20px"><span style="color:black"><span style="color:black">▢</span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"><span style="font-size:20px"> </span>HİZMET ALIMI BİYOMEDİKAL DAYANIKLI TAŞINIR</span></span></span><br><span style="font-size:20px"><span style="color:black"><span style="color:black">▢</span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"><span style="font-size:20px"> </span></span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"> BAKIM-ONARIM ANLAŞMASI KAP.&nbsp; BİYOMEDİKAL DAY. TAŞINIR</span></span></span></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"><br><span style="font-size:20px"><span style="color:black"><span style="color:black">▢</span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"><span style="font-size:20px"> </span></span></span></span><span style="font-size:12px"><span style="color:black"> GARANTİ KAPSAMINDA BİYOMEDİKAL DAYANIKLI TAŞINIR</span></span><br><span style="font-size:20px"><span style="color:black"><span style="color:black">▢</span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"><span style="font-size:20px"> </span></span></span></span><span style="font-size:12px"><span style="color:black">&nbsp;B.&amp;O. KAPSAMINDA KMHB TAR. SAĞLANAN BİYOMED. DAY. TAŞINIR</span></span></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"><span style="font-size:12px"><span style="color:black">MÜDAHALE SONUCU</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">TARİH</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">SAAT</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">MÜDAHALEYİ YAPAN / İMZA</span></span></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"><span style="font-size:12px"><span style="color:black">CİHAZI KULLANICISI / İMZA</span></span></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"><span style="font-size:12px"><span style="color:black">KURUM DIŞI KAYNAK KULLANIM SEBEBİ</span></span></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"><span style="font-size:12px"><span style="color:black">TARİH</span></span></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"><span style="font-size:12px"><span style="color:black">SAAT</span></span></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"><strong><span style="font-size:12px"><span style="color:black">BİYOMEDİKAL TÜKETİM MALZEMESİ TEDARİK</span></span></strong></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"><span style="font-size:12px"><span style="color:black">SIRA NO</span></span></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"><span style="font-size:12px"><span style="color:black">MALZ.TAŞ. KODU</span></span></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"><span style="font-size:12px"><span style="color:black">MALZEME ADI</span></span></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"><span style="font-size:12px"><span style="color:black">MİKTARI</span></span></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"><span style="font-size:12px"><span style="color:black">AÇIKLAMA</span></span></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"><span style="font-size:12px"><span style="color:black">1</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">2</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">3</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">4</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">5</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><strong><span style="color:black">BİYOMEDİKAL TEKNİK HİZMET TEDARİK<br>TEDARİK EDİLECEK BİY. TEKNİK HİZMET TÜRÜ</span></strong></span></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"><span style="font-size:12px"><span style="color:black">&nbsp;</span></span></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"><span style="font-size:12px"><span style="color:black">MÜDAHALEYİ YAPAN / İMZA</span></span></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"><span style="font-size:12px"><span style="color:black">CİHAZ KULLANICISI / İMZA</span></span></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"><span style="font-size:12px"><span style="color:black">KLİNİK MÜHENDİSLİK HİZMETLERİ SORUMLUSU / İMZA</span></span></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"><span style="font-size:12px"><strong><span style="color:black">ARIZA SONUÇ AÇIKLAMA :</span></strong></span></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"><span style="font-size:12px"><strong><span style="color:black">ARIZA BİTİŞ TARİHİ:</span></strong></span></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"><span style="font-size:12px"><span style="color:black">ONAY&nbsp;</span></span><span style="font-size:20px"><span style="color:black"><span style="color:black">▢</span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"><span style="font-size:20px"> </span></span></span></span><span style="font-size:12px"><span style="color:black"> GÖREVLİ TEKNİK PERSONEL / İMZA</span></span></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"><span style="font-size:12px"><span style="color:black">ONAY&nbsp;</span></span><span style="font-size:20px"><span style="color:black"><span style="color:black">▢</span></span></span><span style="font-size:12px"><span style="color:black"><span style="color:black"><span style="font-size:20px"> </span></span></span></span><span style="font-size:12px"><span style="color:black"> CİHAZ KULLANICISI / İMZA</span></span></td></tr></tbody></table>