The purpose of this form is to identify equipment containing embedded systems or date-aware microchips. Complete a separate form for each location.
Department _________________________________________________________________ Date___________________________ Equipment Location _____________________________________ Person Responsible for this Equipment ___________________ Coordinator/Preparer ______________________________________________ Phone/E-Mail _______________________________
List any equipment owned or used by the department that functions, in part, based on date information stored in the device; that requires maintenance based on elapsed time; or that records current date and/or elapsed time information. Attach additional forms if needed. Examples include: fax machines, alarm & security systems, lab and clinical monitoring devices, elevators, patient care devices, and date/time stamping equipment. The last column may be used to check off Year 2000 readiness in Step 2 (Evaluation).
| Equipment Name | Make & Model | Manufacture Date (if known) | This System/Equipment is Used For |
Year 2000 Compliant? (Y/N) |
List or describe any other conditions (including environmental, electric, heat) or supplies (such as liquid helium) which your department or a department member is dependent upon, the loss or delay of which would critically impact department functions.