Healthcare Calibration Report

HEALTHCARE CALIBRATION REPORT

Facility Information

Facility Name:

Patient Information (if device associated with a patient)

Patient Name:

Date of Birth:    Gender:

Patient Phone:    Emergency Contact:

Equipment Identification

Equipment Description:

Serial Number:    Location/Department:

Calibration Details

Calibration Date:    Time:

Performed By (Technician):    Technician ID:

Ambient Temperature:    Relative Humidity:    Barometric Pressure:

Procedure Summary

Measurements & Results

Enter nominal values, measured readings, applicable tolerance, and pass/fail for each check performed.

Deviations and Corrective Actions

Overall Calibration Result:    Pass    Fail

Next Calibration Due (recommended):    Certificate/Report ID:

Certification & Administrative Statement

Certifying statement: I certify that the calibration recorded in this report was performed in accordance with the facility calibration program, applicable manufacturer instructions, and using equipment traceable to recognized national standards. All adjustments, measurements, and acceptance determinations recorded herein are true and complete to the best of my knowledge.

Technician Printed Name:    Technician Badge/ID:

Record Retention: The calibration record will be retained in accordance with facility policy and may be associated with the medical record when the device is used on or assigned to a patient.

Patient Acknowledgment

By signing below, I acknowledge that the equipment listed above that has been used in my care (or assigned to me) has undergone the calibration activities described in this report and that I have received explanation regarding any functional limitations or required precautions if applicable. If signing on behalf of the patient, indicate relationship.

Sign Now