Healthcare Humidifier Certification Document

Healthcare Humidifier Certification Document

Facility Name:     Issuance Date:

Patient Information

Insurance Information

Humidifier Device Identification

Assigned Location:    Owner / Supplier:

Installation, Testing and Maintenance

Installation Date:    Installed By:    Credentials:

Operational and Safety Checks

Humidity Output Verified (setpoint / measured):

Alarms Functioning: Yes No    Power Source Verified: AC Battery

HEPA / Bacterial Filter Installed: Yes No    Filter Replacement Date:

Water and Infection-Control Requirements

Required Water Type (select all that apply): Sterile Distilled Tap (Prohibited unless facility-approved)

Patient Instructed on Replacement and Disposal of Consumables: Yes No

Testing Results and Microbiological Assessment

Patient Acknowledgement and Certifications

I hereby acknowledge that the humidifier described above was issued to me and that I have received operation and infection-control training relevant to this device. I understand the facility's written instructions and the risks associated with improper use, including but not limited to microbial contamination and equipment malfunction. I accept responsibility for following maintenance and water-use requirements and for promptly reporting device malfunction to clinical staff.

I understand that the facility certifies the device was inspected and tested according to facility protocols at the time of issuance and that ongoing maintenance is the responsibility of the entity identified in this form. This certification does not constitute a guarantee against subsequent contamination or failure resulting from misuse, neglect, or circumstances beyond the control of the facility.

Patient has been advised of the right to withdraw acceptance of this device at any time by contacting clinical staff and returning the device as directed. Withdrawal of consent does not negate obligation for charges that may be incurred under applicable policies for device use or replacement.

Authorization for recording and use of health information related to this device for clinical documentation and device management: I acknowledge and authorize the recording and use of my health information for device issuance, maintenance, and clinical care. I do not authorize (patient must discuss with clinical staff).

I certify under penalty of facility policy that the information provided in this Humidifier Certification Document is accurate to the best of my knowledge. I have been provided with the device-specific instructions and the contact information for reporting issues or obtaining servicing.

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