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F-QM-SAF-002-B-V0 — Facility Maintenance Request and Visitor Access Log

Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.

Parent document: LAB-QM-SAF-002 — Facilities and Environmental Conditions (parent is encoded in the form number)

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Document #	F-QM-SAF-002-B-V0	Parent Document	LAB-QM-SAF-002 — Facilities and Environmental Conditions Policy

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Part 1 — Quarterly Facility Infrastructure & Environmental Inspection

Inspection Period:	[ ] Q1 (Jan–Mar) [ ] Q2 (Apr–Jun) [ ] Q3 (Jul–Sep) [ ] Q4 (Oct–Dec)	Date:	YYYY-MM-DD
Inspector Name:	____________________________________, RMT	Lead:	Chief Medical Technologist / LQM

Facility Feature / System	Status (Satisfactory / Deficiency)	Observations & Specific Findings
1. Physical Structure: Floor surfaces joint-free and impervious; walls clean; ceiling tiles tight	[ ] Sat [ ] Def
2. Air Conditioning: Both split-type ACUs running smoothly; ambient room 20–25°C maintained	[ ] Sat [ ] Def
3. Electrical & Power: Outlets grounded; emergency generator transfer operational	[ ] Sat [ ] Def
4. Plumbing & Sinks: Water pressure continuous; drainage unobstructed; eyewash functional	[ ] Sat [ ] Def
5. Lighting: Bench illumination adequate; emergency backup lighting functional	[ ] Sat [ ] Def
6. Fire Safety: Fire extinguisher tagged; evacuation corridor clear	[ ] Sat [ ] Def
7. Biosafety Access: Biohazard signage intact on main entry door; restricted entry enforced	[ ] Sat [ ] Def

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Part 2 — Facility Deficiency, Maintenance Request & Work Order Register

Start a request at once when any structural, plumbing, electrical, or air conditioning fault is found.

Work Order #	Date Logged	Priority: [R] Routine / [U] Urgent / [E] Emergency	Work Completed Date
1	YYYY-MM-DD	[ ] R [ ] U [ ] E	YYYY-MM-DD
2	YYYY-MM-DD	[ ] R [ ] U [ ] E	YYYY-MM-DD
3	YYYY-MM-DD	[ ] R [ ] U [ ] E	YYYY-MM-DD

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Part 3 — Post-Repair Handover & Environmental Clearance Sign-Off

Work Order #	Date Verified	Post-Repair Environmental Condition Verified?	Worksite Decontaminated & Cleared?	Verified By (CMT/LQM Signature)
1	YYYY-MM-DD	[ ] Yes — Temperature / utility restored to baseline	[ ] Yes — Cleaned and disinfected
2	YYYY-MM-DD	[ ] Yes — Temperature / utility restored to baseline	[ ] Yes — Cleaned and disinfected

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Part 4 — Controlled Laboratory Visitor Access Log

Notice: The Clinical Laboratory is a restricted area. All non-laboratory personnel (contractors, service engineers, sales representatives, visitors) must register on entry, wear PPE, and stay with an escort at all times.

Log #	Date	Time In	Time Out
1	YYYY-MM-DD	HH:MM	HH:MM
2	YYYY-MM-DD	HH:MM	HH:MM
3	YYYY-MM-DD	HH:MM	HH:MM
4	YYYY-MM-DD	HH:MM	HH:MM
5	YYYY-MM-DD	HH:MM	HH:MM
6	YYYY-MM-DD	HH:MM	HH:MM

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Part 5 — Monthly Supervisory Review & Endorsement

5.1 Medical Technologists

We confirm that visiting contractors were escorted and worksites were cleaned and verified following repair.

Technologist Name	PRC License Number	Date	Signature

5.2 Laboratory Aides

We confirm that entrances were monitored and facility defects were reported promptly.

Laboratory Aide Name	Assigned Duty Station	Date	Signature

5.3 Chief Medical Technologist / Laboratory Quality Manager

Facility Review Status: [ ] All pending work orders resolved [ ] Environmental controls within limits
Signature: ________________________________________ Date: ____________________

5.4 Pathologist / Head of Laboratory

Signature: ________________________________________ Date: ____________________