Healthcare Scale Inspection Form

HEALTHCARE SCALE INSPECTION FORM

Inspection Overview

Inspection Date:   Time:

Inspector Information

Facility & Location

Scale Identification

Manufacturer:   Model:   Serial No.:

Asset / Inventory ID:   Date of Manufacture:

Capacity:   Resolution:

Scale Type: Wheelchair Stand-on Infant Bed Platform Bariatric

Pre-Inspection Checklist

For each item mark the observed status and provide comments where relevant.

Calibration & Accuracy Tests

Record test weights and observed indications. Attach instrument test weights traceable to accepted standards where applicable.

Test Weight Applied:   Indicated Weight:   Deviation:

Reference Weight ID / Traceability:   Used Test Weight Condition:

Acceptable Tolerance (facility specification):   Observed Within Tolerance: Yes No

Conclusions & Corrective Action

Overall Result: Pass Fail

Recalibration Required: Yes No

Parts Replaced:

Calibration Certificate

Certificate Issued: Yes No

Certificate No.:   Certificate Date:

Next Calibration Due:

Patient Weighing (If Applicable)

Complete this section only if a patient was weighed as part of the inspection or testing.

Date of Birth:   Gender:

By signing below in the Patient Weighing section, the patient (or guardian) acknowledges that weight data recorded during this inspection may be entered into facility records. The inspector and facility attest that recorded values are limited to clinical or equipment verification purposes.

Inspector Certification

I certify under penalty of administrative action that the information documented on this form accurately reflects the condition and test results of the scale identified above. Tests were performed in accordance with accepted metrological practices and facility procedural requirements. Any deviations, repairs, or conditions affecting safe patient use are recorded herein. This certification applies only to the specific unit and location inspected and does not extend to other equipment not explicitly identified.

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