Medical Device Installation Site Assessment Form
Facility Information
Facility Name
Facility Address
Contact Person
Contact Phone
Contact Email
Device Information
Device Name/Model
Device Serial Number
Intended Installation Location
Site Assessment
Is sufficient space available for installation?
Yes
No
Flooring Type
Room Access (door width, stairs, elevator, etc.)
Is there adequate ventilation?
Yes
No
Power Requirements
Is proper grounding available?
Yes
No
Network Requirements
Environmental Conditions (temperature, humidity, etc.)
Safety Considerations
Other Requirements/Comments
Assessor Details
Assessor Name
Assessment Date