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DS.FR.046 - MEDİKAL DEPO TEMİZLİK KONTROL FORMU

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Demo Hastanesi (Prokalite.Com) MEDİKAL DEPO TEMİZLİK KONTROL FORMU

Doküman Kodu: DS.FR.046

Yayın Tarihi: 01.11.2016

Revizyon Tarihi: 10.03.2023

Revizyon No: 3

Sayfa: Otomatik

**ORTA RİSKLİ ALAN

Zemin Temizliği

Kapı kolları, elektrik düğmeleri,

Çöplerin toplanması

Pencere önü, radyatörler

Çöp kovaların temizliği

Kapılar

Buzdolabı

Depo, raflar

Tüm yüzeyler haşerelere karşı ilaçlama

Duvarlar, camlar, tavan

Temizlik malzemeler i temizliği

Kontrol Eden Birim Sorumlusu

Kontrol Eden Kurum Sorumlusu

Tarih

Günde 2 defa gerekirse hemen

Günde 1 defa gerekirse hemen

Günde 1 defa gerekirse hemen

Günde 1 defa gerekirse hemen

Haftada 1 defa gerekirse hemen

Haftada 1 defa gerekirse hemen

Haftada 1 defa gerekirse hemen

Haftada 1 defa gerekirse hemen

Ayda 1 defa

Ayda 1 defa

Her kullanımdan sonra ve gün sonunda

07:00

14:00

07:00

07:00

07:00

Pazartesi

Salı

07:00

07:00

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<p>**ORTA RİSKLİ ALAN</p><table style="border-collapse:collapse; width:1290px" class=" cke_show_border" cellspacing="0"><tbody><tr><td style="border-bottom:none; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:52px; vertical-align:middle; width:75px"><br></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:left; vertical-align:middle; width:103px"><span style="font-size:13px"><span style="color:black">Zemin Temizliği</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:85px"><span style="font-size:13px"><span style="color:black">Kapı kolları, elektrik düğmeleri, </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:83px"><span style="font-size:13px"><span style="color:black">Çöplerin toplanması</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:86px"><span style="font-size:13px"><span style="color:black">Pencere önü, radyatörler</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:left; vertical-align:middle; width:85px"><span style="font-size:13px"><span style="color:black">Çöp kovaların temizliği</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:88px"><span style="font-size:13px"><span style="color:black">Kapılar</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:86px"><span style="font-size:13px"><span style="color:black">Buzdolabı</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:85px"><span style="font-size:13px"><span style="color:black">Depo, raflar</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:81px"><span style="font-size:13px"><span style="color:black">Tüm yüzeyler haşerelere karşı ilaçlama</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:64px"><span style="font-size:13px"><span style="color:black">Duvarlar, camlar, tavan</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:96px"><span style="font-size:13px"><span style="color:black">Temizlik malzemeler i temizliği</span></span></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:middle; width:82px"><span style="font-size:13px"><strong><span style="color:black">Kontrol Eden Birim Sorumlusu</span></strong></span></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:middle; width:82px"><span style="font-size:13px"><strong><span style="color:black">Kontrol Eden Kurum Sorumlusu</span></strong></span></td></tr><tr><td style="border-bottom:none; border-left:1px solid black; border-right:1px solid black; border-top:none; height:69px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:13px"><span style="color:black">Tarih</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:103px"><span style="font-size:13px"><span style="color:black">Günde 2 defa gerekirse hemen</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:85px"><span style="font-size:13px"><span style="color:black">Günde 1 defa gerekirse hemen</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:83px"><span style="font-size:13px"><span style="color:black">Günde 1 defa gerekirse hemen</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:86px"><span style="font-size:13px"><span style="color:black">Günde 1 defa gerekirse hemen</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:85px"><span style="font-size:13px"><span style="color:black">Haftada 1 defa gerekirse hemen</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:88px"><span style="font-size:13px"><span style="color:black">Haftada 1 defa gerekirse hemen</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:86px"><span style="font-size:13px"><span style="color:black">Haftada 1 defa gerekirse hemen</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:85px"><span style="font-size:13px"><span style="color:black">Haftada 1 defa gerekirse hemen</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:81px"><span style="font-size:13px"><span style="color:black">Ayda 1 defa</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:middle; width:64px"><span style="font-size:13px"><span style="color:black">Ayda 1 defa</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:96px"><span style="font-size:13px"><span style="color:black">Her kullanımdan sonra ve gün sonunda</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:26px; vertical-align:middle; width:75px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><span style="font-size:13px"><span style="color:black">07:00</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><span style="font-size:13px"><span style="color:black">14:00</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:85px"><span style="font-size:13px"><span style="color:black">07:00</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:middle; width:83px"><span style="font-size:13px"><span style="color:black">07:00</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:86px"><span style="font-size:13px"><span style="color:black">07:00</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:middle; width:85px"><span style="font-size:13px"><span style="color:black">Pazartesi</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:88px"><span style="font-size:13px"><span style="color:black">Salı</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:86px"><span style="font-size:13px"><span style="color:black">07:00</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:85px"><span style="font-size:13px"><span style="color:black">07:00</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:81px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:88px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:81px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; 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border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; 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border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; 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border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; 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text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; 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border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; 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border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; 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text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; 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text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; 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border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:88px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:81px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:88px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:81px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:32px; text-align:center; vertical-align:middle; width:75px"><span style="font-size:12px"><span style="color:black">…/…/202…</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:52px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:51px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:83px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:88px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:86px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:85px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:81px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:64px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:96px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:82px"><br></td></tr></tbody></table>

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