Healthcare Tank Inspection Form

HEALTHCARE TANK INSPECTION FORM

This form documents the inspection of medical gas tanks, cylinders, or storage vessels intended for patient care or facility use. The inspector certifies that the inspection was performed in accordance with applicable facility policies and recognized safety and testing standards. Records related to this inspection will be retained as medical-equipment maintenance records and handled in accordance with facility confidentiality policies.

Inspection Details

Inspection ID:   Inspection Date:

Patient / Recipient Information (if tank is assigned to a patient)

Date of Birth:   Gender:

Phone:   Emergency Contact:   Emergency Phone:

Insurance / Coverage (if applicable)

Policy Number:   Group Number:   Subscriber Name:

Tank Identification

Serial Number:   Manufacturer:   Model:

Tank Type: Oxygen Nitrous Oxide Medical Air CO2 Other

Capacity (liters):   Fill Pressure (psi):   Certificate / Tag Number:

Last Hydrostatic Test Date:   Next Hydrostatic Due:

Location of Tank

Department / Service:   Room / Location:

Inspection Checklist (mark findings and provide readings)

External Condition (dents, gouges, corrosion): Acceptable Issue noted

Valve & Outlet Operation: Operable Leak or sticking observed

Pressure Gauge Reading (psi):   Regulator Condition: OK Replace

Labeling & Color Coding Legible: Yes No   Tamper Seals Intact: Yes

Leak Test Performed: Yes No   If performed, Leak Test Result:

Corrective Actions / Remediation

Action Assigned To:   Target Completion Date:

Privacy & Authorization

By checking the box below, the signer acknowledges receipt of facility privacy practices relevant to inspection records and authorizes use and disclosure of inspection information as necessary for clinical care, equipment maintenance, and regulatory reporting.

I acknowledge the privacy notice and authorize recordation and use of inspection information as described.

This authorization is valid until:

Certification

I certify under penalty of facility administrative discipline that, to the best of my knowledge, the inspection set forth above was completed on the stated date and that the findings are true and complete. Where unsafe conditions were identified, I have documented corrective actions and/or removed the tank from service pending remediation. The facility retains the right to remove any tank from clinical use if it poses a risk to patient care or safety.

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