SAMPLE Preventive-Maintenance-Checklist

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Preventive Maintenance Checklist for Building

Date: January 1, 2024

Prepared By: J. Dela Cruz

Approved By: M. Marcos

Person Due Date


Equipment Action
No. Location Schedule Date Checked Action Required responsible for Signature for Next
Description Completed
checking Check
Lighting (Bulb at the January 5, For replacement February
1 Monthly January 7, 2024 M. Asino
lobby) 2024 of busted lights 5, 2024
Preventive Maintenance Checklist for Medical Equipment
Date: January 1, 2024

Prepared By: J. Dela Cruz

Approved By: M. Marcos

Person Due Date


Equipment Action
No. Schedule Date Checked Action Required responsible for Signature for Next
Description Completed
checking Check
February
1 Autoclave Monthly January 5, 2024 None N/A M. Asino
5, 2024

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Preventive Maintenance Checklist for Non-Medical Equipment
Date: January 1, 2024

Prepared By: J. Dela Cruz

Approved By: M. Marcos

Person Due Date


Equipment Action
No. Schedule Date Checked Action Required responsible for Signature for Next
Description Completed
checking Check
February
1 Laptop/Computer Monthly January 5, 2024 None N/A M. Asino
5, 2024

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