CCEM 2

6 GENERATORS

FACILITY CODE:
For National Level use only.

EQUIPMENT RECORD OF (Fill in a separate form for each piece of equipment at health facility and number all forms)
Name of (health) facility: RURAL HEALTH UNIT 3 LUBAO/ NO GENERATOR
Generator information

1. Model name: 8. Used for:

Mark ALL boxes that apply
Refrigerators or freezers
2. Manufacturer: Cold rooms
Lighting
Other
3. Serial number: 9. Year acquired:

4. Number of phases: 10. Source of supply:

Mark only ONE box Mark only ONE box
One DOH
Three CHD
5. Power rating:(kVA) Donation/NGO, specify :
LGU
Unknown
6. Power source: 11. Working status:
Mark only ONE box Mark only ONE box
Diesel Working well & fuel available
Gas Working well but no budget for gas
Working but needs repair
Not working
7. Automatic start mechanism? 12. Equipment utilization:
Mark only ONE box
Yes Mark only ONE box

No In use
In storage
Not used & available for allocation
Not used & not available for allocation