Annexure – A

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Annexure : B

Installation completion Certificate cum Detail Sheet of Equipment ( This certificate is to be signed by end user/doctor/technical person/HOD/BME/store keeper and should be maintained by Hospital )

1. Name of Hospital : ____________________________________________________

2. Department : ____________________________________________________

3. Purchase Order No. & Date : __________________________________________________

4. Name of Equipment : ____________________________________________________

5. Model No. : ____________________________________________________

6. Sr. No. of Equipment : ____________________________________________________

7. UNI (Unique no. of Equipment) of Hospital : _____________________________________

8. Supplier / Manufacture Name & Contact No. : ___________________________________

9. Received From(GMSCL/Program/Donation): _____________________________________

10. Transfer From: (If applicable): ________________________________________________

11. Date of Received : __________________________________________________________

12. Date of Installation : ____________________________________________________

13. Dead Stock Register Page No. : ________________________________________________

14. Warranty Duration: 12/24/36/48/60(Months): ___________________________________

15. Equipment as per Specification : Yes No

16. Training Received during installation : Yes No

17. AT (Acceptance Tender) / RC (Rate Contract) copy received : Yes No

18. Grant / Funding Source:______________________________________________________

19. Type of Payment : In Rs. Foreign Currency

20. If Payment is to be done through your institute than Payment is done or not?

Yes No N.A.

21. If Payment is to be done through GMSCL than Original Certified Bill is sent to GMSCL or

not? Yes No N.A.

The above Equipment is installation and checked according to specification give in purchase order and

equipment is satisfactory installed and working and is noted in our deadstock Register No.___ with page

no.____ and further details of equipment would be maintained by the Hospital as per Annexure : C

Name of user : Contact No. : Sign. :

Name HOD: Contact No. : Sign. :

Medical Equipment Coordinator : Contact No. : Sign. :

Head of Institute

Sign. :

Stamp. :

Annexure – c

Service Satisfaction Certificate

(This certificate is to be signed by end user/doctor/technical person/HOD/BME/store keeper and should be maintained year wise by Hospital)

(During Warranty / CMC)

Equipment under warranty or CMC: ___________________________________________

(1) Purchase Order No. & Date: ________________________________________________

(2) Name of Equipment : __________________________________________________

(3) Model No. : __________________________________________________

(4) Sr. No. of Equipment : __________________________________________________

(5) UNI (Unique no. of Equipment) of Hospital : ___________________________________

(6) Supplier / Manufacture Name & Contact No. : __________________________________

(7) Date of Installation : __________________________________________________

(8) No. of test details of usage of Equipment : _____________________________________

(9) CMC done by (Local / GMSCL) : ___________________(if under CMC)

(10) Service provider / Maintenance Contact No. / Address :

_______________________________________________________________________

(11) No. of Year of Warranty / CMC : _____ year

(12) Period of Warranty / CMC : _____________ to ____________

Free Preventive Maintenance Services Details during Warranty / CMC:

Sr. No. Services Number

Date of Service Service Engineer

contact and contact number

Hospital authorized person sign

Remarks

1

2

3

4

Other break down details:

This is to certify that above given Information related service of Equipment during

warranty has been ________ (given/Not given) by company & all service report and record

would be maintained by Hospital.

Name of user : Contact No. : Sign. :

Name HOD: Contact No. : Sign. :

Medical Equipment Coordinator : Contact No. : Sign. :

Head of Institute

Sign. :

Stamp. :

Name of CDMO/Dean/Superintedant :- Contact No.:-

ક્રમ ાંક ડિપ ર્ટ મેન્ર્ન ાં ન મ સ ધનન ાં ન મ સ ધનન ાં

મોિેલસ ધનનો સીરીયલ નાં.

સપ્લ યર /ઉત્પ દક પેઢીન ાં ન મ

ખરીદ ઓિટર નાં. & ત રીખ

(GMSCL

purchase/Direct

purchase/Donation etc)

ઈન્્ર્ોલેશન

ત રીખવોરાંર્ી પરૂ્ટ થય ત રીખ

સ ધનની ્થ પપત

જગ્ય

વોરાંર્ી પરૂ્ટ થય બ દ સ ધન

(AMC/CMC) મ ાં છે

કે કેમ?

જો હ તો તેનો સમયગ ળો

Warrenty/CMC/

AMC દરપમય ન

પેઢીએ ફ્રી સપવિસ

આપેલ છે કે કેમ?

સ ધનની હ લની પડરસ્્થપત

(Working/Need

Repair/ Need

Condemn)

સ ધનની ડકિંમતસ ધનનો આઈિેન્ર્ીફીકેશન

નાં/ િેિ ્ર્ોક નાંરીમ કટસ

Sr. No

(1)

Name of

Department

(2)

Name of Equipment

(3)

Model of

Equipment

(4)

Sr. No. of

Equipment

(5)

Supplier/Manufacturer

(Name & address)

(6)

Purchase Order No &

Date. Of GMSCL

purchase/Direct

purchase/Donation etc

(7)

Date of

Installation

(8)

Date of Expiry

of warranty

(9)

Location of

Equipment

(10)

If warranty has

expired, Is the

Equipment under

any maintenance

contract(CMC/

AMC/NO)

(11)

If Yes ,then

mentioned

Duration of

maintenance

Contract

(12)

Warrenty/CMC/

AMC services

had been given

by service

provider (yes/no)

(13)

Current status of

Equipment

(Working/Need

Repair/ Need

Condemn)

(14)

price/cost(15)

Equipment

Hospital

Identification

no(desk stok regi

num)(16)

Remarks

(If any)

(17)

Authorised Signatory

IMP Note:- While sending Equipment inventort report through mail, It is compulsary to do e-mail from hospital authentic email ID and write hospital name in subject line while doing Email(gmscl.em.bme@gmail.com).

You can change the size the width of the column according to requirement.

Gujarat Medical Services Corporation Limited,Gandhinagar

Equipment Inventory report

District:- Name of Hopsital :-

Annexure-D

Annexure – E

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